Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Mountain Post Acute during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, aphasia, and cataracts, care planned as requiring total assistance with ADLs, experienced an assisted fall during a transfer to a shower chair with two CNAs when the resident was unable to bear weight and was lowered to the floor. The CNAs did not report the incident to the charge nurse, and the event went undocumented until an investigation was started after imaging later revealed acute mildly displaced fractures of the proximal tibia and proximal fibular shaft. This unreported fall and delayed recognition of injury occurred despite facility policies requiring staff training to identify and report accident hazards and to manage falls and fall risk.
A resident with anoxic brain damage, tracheostomy, and G-tube, assessed as high fall risk and totally dependent for ADLs with a documented need for a two-person assist for bed mobility and transfers, was repositioned in bed by a single CNA. The CNA, working alone near the end of a shift, turned the resident while the resident was close to the edge of the bed, resulting in a fall to the floor and subsequent transfer to the hospital with abnormal vital signs, contrary to the care plan and facility ADL policy.
A resident with COPD and cirrhosis who was admitted to hospice care was not accurately coded as receiving hospice services in the MDS assessment. The MDS Director completed Section O without indicating hospice care, despite supporting documentation and physician orders. The DON confirmed the assessment was inaccurate and not in compliance with facility policy.
A resident with atrial fibrillation and a history of falls did not have a care plan addressing anticoagulant use, and injury prevention interventions from the fall risk care plan were not implemented. Staff confirmed the absence of a care plan for anticoagulant monitoring and the lack of a required floor mat, despite the resident's identified risks.
Three residents with significant mobility impairments and fall risks were not provided with required safety interventions, including intact wheelchair armrests and floor mats as ordered in their care plans. Staff and nursing leadership confirmed that these interventions were not implemented as required, despite clear physician orders and facility policy.
A resident with no natural teeth did not receive timely dental services or replacement dentures after readmission. Despite a treatment plan and care plan requiring dental referrals and monitoring, no referral was made, and the resident reported difficulty chewing and not being asked about dentures upon admission. The Social Services Director confirmed the lapse in following up on dental care, contrary to facility policy.
Staff failed to follow infection prevention protocols, including leaving food containers and utensils on a bathroom floor, not performing hand hygiene after glove removal and exiting a room of a resident on Enhanced Barrier Precautions, and allowing trash bins in multiple rooms to overflow. These actions did not meet the facility's infection control standards.
Unreported Assisted Fall and Fracture During Transfer to Shower Chair
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies on resident safety, supervision, and fall management for a resident with significant functional and cognitive impairments. The resident was last admitted with diagnoses including hemiplegia, hemiparesis, aphasia, and age-related cataract, and a history and physical documented that the resident was not able to make their own decisions. The resident’s care plan, dated December 5, 2025, identified an ADL self-care performance deficit related to right-sided hemiplegia and specified that the resident required total assistance with ADLs. On March 14, 2026, during a transfer to a shower chair in the resident’s room with assistance from two CNAs, the resident was unable to bear weight and was lowered to the floor in a controlled manner. The CNAs involved did not report this assisted fall incident to the charge nurse at the time it occurred, and one CNA continued her shift without notifying nursing staff. The incident was not documented or reported until March 19, 2026, when the facility initiated an investigation after the resident was identified with a fracture of unknown origin. Radiology results from March 19, 2026, showed acute mildly displaced fractures of the proximal tibia and proximal fibular shaft of the left leg. The facility’s investigation concluded that the resident had experienced an assisted fall during the transfer and that the event was not reported, which limited the ability for timely clinical assessment and intervention. This sequence of events occurred despite facility policies stating that the environment should be as free from accident hazards as possible, that resident safety and supervision are priorities, that employees must be trained to identify and report accident hazards and prevent avoidable accidents, and that staff will identify interventions to prevent falls and minimize complications from falling.
Failure to Follow Two-Person Assist Requirement During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to provide ADL care and services in accordance with a resident’s assessed needs and care plan, specifically related to safe bed mobility and transfers. The resident was admitted with significant medical conditions including anoxic brain damage, tracheostomy status, and gastrostomy status, and had been assessed as totally dependent for self-care and mobility. A Fall Risk Evaluation showed a high fall risk score of 11, and the resident’s care plan for Activities of Daily Living documented that the resident required total assistance for ADLs, was non-ambulatory, and that the resident’s wife preferred a two-person assist for bed mobility, transfers, and getting out of bed. The MDS Section GG further indicated a score of 1 for self-care and mobility, meaning the resident was dependent and required the assistance of two or more helpers to complete activities. Despite these assessments and care plan directives, on the morning of November 8, 2025, a CNA provided incontinence care and repositioned the resident in bed alone, without a second staff member. The CNA reported that he was working alone due to a lack of assistance and the impending end of his shift, and acknowledged that protocol required a two-person assist for this total-care resident. He noted the resident was very close to the edge of the bed and, when he turned the resident onto his side, the resident fell from the bed. Nursing notes documented that the CNA informed the charge nurse that the resident was on the floor, and that the resident was subsequently sent to the hospital after a witnessed fall, with three sets of abnormal vital signs recorded (BP 79/66, pulse 124, oxygen saturation 85%). The facility’s ADL policy stated that appropriate care and services are to be provided for residents unable to carry out ADLs independently, in accordance with the plan of care, which was not followed in this incident.
Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident who was receiving hospice care. The Minimum Data Set (MDS) assessment, specifically Section O which documents special treatments and programs, was completed by the MDS Director but did not indicate that the resident was under hospice care, despite documentation in the clinical census and physician's orders confirming hospice services. During interviews and record reviews, the MDS Director acknowledged responsibility for completing Section O and confirmed that the resident should have been coded as receiving hospice care, but was not. Further review of facility policy revealed that assessments are to be completed by qualified staff and must accurately reflect the resident's status, with all contributors attesting to the accuracy of the information. The Director of Nursing confirmed that the assessment was inaccurate and that facility policy was not followed in this instance. The resident involved had diagnoses including COPD and cirrhosis of the liver and was admitted to hospice care, but this was not reflected in the MDS assessment.
Failure to Develop and Implement Comprehensive Care Plans for Anticoagulant Use and Fall Prevention
Penalty
Summary
The facility failed to develop and implement comprehensive and person-centered care plans for a resident with multiple medical needs. Specifically, there was no care plan addressing the resident's use of an anticoagulant medication, despite the resident having a diagnosis of atrial fibrillation and an active order for Eliquis. Both the Assistant Director of Nursing and the Director of Nursing confirmed during interviews and record reviews that a care plan for anticoagulant use was not in place, and acknowledged the importance of monitoring for side effects such as discoloration, bleeding, and bruising. Additionally, the facility did not implement injury prevention interventions identified in the resident's fall risk care plan. The resident, who had a history of falls, muscle weakness, hemiplegia, and recent fractures, was assessed as a fall risk and had a care plan intervention for a floor mat to be placed on the left side of the bed. Multiple observations confirmed that the floor mat was not present, and both the resident and staff verified it had not been in place since admission. The DON acknowledged that the intervention was not implemented as required, which did not follow the established care plan.
Failure to Maintain Safe Environment and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. One resident, who had diagnoses including cerebral palsy, diabetes, and paraplegia, was observed using a wheelchair with both armrest covers peeled off, exposing rough and uneven surfaces. The resident reported the damage had been present for six months, and the Director of Rehabilitation Services confirmed that such damage could cause skin abrasions or tears. The resident's care plan identified a risk for skin integrity impairment and required elimination of potential causative factors, but the wheelchair armrests were not maintained in good condition as per facility policy. Two other residents, both with significant mobility impairments and a history of falls, did not have floor mats in place as ordered for injury prevention. One resident with Parkinson's disease and hemiplegia had a physician's order and care plan intervention for a right-side floor mat to prevent injury from falls, but no mat was present during multiple observations. Nursing staff and the Assistant Director of Nursing confirmed the absence of the mat and acknowledged it was required by the care plan and physician order. The second resident, with muscle weakness, hemiplegia, and a recent history of falls and fractures, also had a care plan and physician order for a floor mat on the left side of the bed. Observations on consecutive days confirmed the absence of the mat, and both the resident and staff verified that the intervention had not been implemented since admission. The DON acknowledged that the lack of a floor mat was not in accordance with the care plan and physician order, and that the facility's fall prevention policy was not followed.
Failure to Provide Timely Dental Services and Denture Replacement
Penalty
Summary
The facility failed to provide necessary dental services, including the timely provision and replacement of dentures, for a resident who had no natural teeth. Upon review, it was found that the resident was admitted and later readmitted to the facility, with documentation indicating intact cognitive skills and a need for dentures. The resident's treatment plan included a referral for new dentures, and the care plan required coordination for dental care and monitoring for oral issues. However, there was no evidence that a referral for dental services was made after the resident's readmission, despite orders for a dental evaluation and treatment as indicated. During an interview, the resident reported not being asked about dentures upon admission and expressed difficulty chewing, requiring staff to provide chopped food even though the resident was on a regular diet. The Social Services Director confirmed that it was their responsibility to follow up on the resident's dentures and acknowledged that this had not been done. The facility's policy stated that social services would assist with dental appointments and arrangements, and that lost or damaged dentures would be addressed per regulatory requirements, but these procedures were not followed in this case.
Failure to Implement Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement infection prevention and control practices as required by policy, resulting in multiple deficiencies. During an observation, a gray basin containing four food containers and two utensils was found on the bathroom floor between two residents' rooms. Certified Nurse Assistant 1 confirmed that this was not standard practice and that such items should not be kept on the bathroom floor. The Infection Preventionist also acknowledged that this did not meet facility expectations or infection control protocols, as outlined in the facility's Infection Prevention and Control Program policy. Additionally, a respiratory therapist did not perform hand hygiene after exiting a resident's room or after removing gloves, despite the resident being on Enhanced Barrier Precautions to prevent the spread of multi-drug-resistant organisms. The therapist admitted to not following the expected hand hygiene protocol. Furthermore, observations revealed that trash bins in three residents' rooms were full and overflowing, which the Infection Preventionist confirmed was inconsistent with maintaining a safe and sanitary environment as required by facility policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Yucaipa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside Post Acute | 1.9 mi | ★★★★★ | 2 | 0 |
| Yucaipa Hills Post Acute | 2.1 mi | ★★★★★ | 9 | 0 |
| University Post Acute | 4 mi | ★★★★★ | 9 | 0 |
| Oak Glen Post Acute | 6.2 mi | ★★★★★ | 0 | 0 |
| Highland Care Center Of Redlands | 6.3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.