A list of the most recent deficiencies for Cedar Mountain Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-09 | 2023-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-08 | 2023-08-03 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Use approved construction type or materials. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-16 | 2023-04-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-03-16 | 2023-04-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-03-16 | 2023-04-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-16 | 2023-04-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-16 | 2023-04-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-04-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-16 | 2023-04-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-16 | 2023-04-13 | N |
| Provide or obtain dental services for each resident. | Health | 2023-03-16 | 2023-04-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-04-13 | N |
| Use approved construction type or materials. | Fire Safety | 2023-03-16 | 2023-03-29 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-01-10 | 2023-01-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-10 | 2022-11-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-15 | 2021-12-30 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-12-13 | 2021-12-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-07 | 2021-08-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-15 | 2021-06-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-12 | 2021-05-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-20 | 2021-05-04 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-06 | 2020-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-06 | 2020-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-06 | 2020-02-06 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Use approved construction type or materials. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-18 | 2020-01-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-20 | 2019-05-07 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-02-20 | 2019-05-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-02-20 | 2019-05-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-20 | 2019-05-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-20 | 2019-05-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-20 | 2019-05-07 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2019-02-20 | 2019-05-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-20 | 2019-05-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-20 | 2019-05-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-21 | 2019-01-18 | N |
| Provide activities to meet all resident's needs. | Health | 2018-12-21 | 2019-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-21 | 2019-01-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-21 | 2019-01-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-21 | 2019-01-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-21 | 2019-01-18 | N |
