Cedar Pine Post Acute

In the surveyor’s words

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

• Immediate jeopardy, patternF812Apr 16, 2023

  Based on observation, interview and record review, the facility failed to follow safe food handling practices for two of two sampled residents (Resident 1 and 2) to prevent an unknown gastrointestinal (GI) outbreak (a sudden rise in the number of cases of an infectious disease) by: 1. Failed to ensure Kitchen Staff 1 (KS 1) did not work in the facility kitchen and prepare food for the residents on [DATE] and from [DATE] to [DATE] while KS 1 was experiencing diarrhea (the passage of three or more loose or liquid stools per day) abdominal pain, vomiting, nausea, fever, and loss of appetite. 2. Failed to store refrigerated food items in accordance with professional standards for food service. […]

• Immediate jeopardy, patternF880Apr 16, 2023

  Based on observation, interview, and record review the facility failed to implement their policy and procedure for infection control to prevent infectious disease outbreak (a sudden rise in the number of cases of an infectious disease) for two of two residents (Resident 1 and 2) by: 1. Failed to ensure Kitchen Staff 1 (KS 1) did not work in the facility kitchen and prepare food for the residents on 3/27/2023 and from 3/30/2023 to 4/3/2023 while KS 1 was experiencing diarrhea (the passage of three or more loose or liquid stools per day) abdominal pain, vomiting, nausea, fever, and loss of appetite. 2. […]

• Immediate jeopardy, isolatedF689Apr 19, 2025

  Based on observation, interview, and record review the facility failed to ensure one (1) of 1 sampled resident (Resident 1) who was assessed at risk for elopement (a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) did not elope after going out- on- pass (OOP, temporary permission of a resident to leave the facility in a specified time) on 4/15/2025 at 6 PM by failing to: 1. Develop a care plan and interventions to address Resident 1's risk for elopement. 2. Implement procedures based on the facility's Elopement Risk policy to search for Resident 1 when Resident 1 did not return to the facility while OOP. 3. […]

• Actual harm, isolatedF690Aug 28, 2025

  Based on interview and record review, the facility failed to provide the appropriate treatment and service to prevent urinary tract infection (UTI- infection of the urinary tract) to one (1) of two (2) sampled residents (Resident 1) who was admitted at the facility with indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine when a person is unable to urinate on their own) by failing to: 1. Monitor and document Resident 1's change of condition (COC) that was observed by facility staff on 8/14/2025 and on 8/21/2025 of dark/ brown colored urine (normal urine color is clear and yellow) in the indwelling catheter bag. 2. […]

• No harm, potential for more than minimal, patternF656Jun 26, 2026

  Based on interview and record review, the facility failed to develop an individualized resident-centered care plan (CP, a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs)for four (4) of 23 sampled residents (Residents 16, 22, 35 and 73) in accordance with the facility's policy and procedure (P&P) by failing to have a care plan for:Resident 22's use of Montelukast (Singulair, a medication used to treat lung inflammation which has potentially dangerous side effects)Resident 73's use of a low air loss mattress (LALM, mattress overlay used to relieve pressure from a resident's back and help wounds heal).Resident 35 to have activities in accordance with the resident's activity assessment.Resident 16's noncompliance (when a… […]