Health inspection·November 25, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings:A review of Resident 12's admission Record, dated 9/26/25, indicated Resident 12 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD- a progressive lung disease which blocks air flow making breathing difficult) and cirrhosis of the liver (scarring of the liver, caused by chronic injury or long-term liver disease) among others.A review of the facility document titled, Order Entry, a physician's order for Resident 12, dated 7/8/2025, indicated, May admit to (Name of company) Hospice under (name of physician) Dx (abbreviation for diagnosis): COPD.A review of the facility's Clinical Census, dated 9/26/25, indicated Resident 12 was under hospice services, with effective date 7/8/2025.During a concurrent interview and record review with the MDS Director (MDS 1), on 9/26/25, at 11:46 AM, the MDS Significant Change assessment Section O (Special Treatment, Procedures and Programs) was reviewed. MDS 1 stated she was responsible for the assessment under Section O where part of the assessment would indicate if a resident was under hospice care. MDS 1 stated she completed the Section O for Resident 12. A review of Resident 12's Section O indicated an entry of No for Hospice care. MDS 1 stated Resident 12 was under Hospice care and should have been coded as such under Section O.During a concurrent interview and record review with the Director of Nursing (DON), on 9/26/25 at 3:00 PM, the facility's undated policy and procedure (P&P) titled, Resident Assessment, was reviewed. The P&P indicated, .Policy Interpretation and Implementation.10. Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline.11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. The DON stated the assessment for Resident 12 was not accurate because the resident was not coded under hospice care, and further stated the policy was not followed. Residents Affected - Few Page 1 of 9 555494 555494 11/25/2025 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings:a. A review of Resident 25's admission Record, indicated Resident 25 was readmitted to the facility on [DATE] with diagnoses including Unspecified Atrial Fibrillation (Afib - an irregular heartbeat that commonly causes poor blood flow).A review of Resident 25's Minimum Data Set (MDS- a standardized assessment tool), dated 8/15/25, indicated Resident 25's cognitive (ability to think and reason) skills for decision making were intact. The MDS indicated Resident 25 had a diagnosis of Atrial Fibrillation with medication including an anticoagulant.A review of Resident 25's Order Summary Report (a document that consolidates prescription information) dated 9/24/25, indicated Resident 25 had an order for Eliquis (an anticoagulant medication used to treat and prevent blood clots) Oral Tablet 2.5 milligrams (mg- a unit of measure) two times per day for Afib.During a concurrent interview and record review of Resident 25's Care Plans, with the Assistant Director of Nursing (ADON), on 9/24/25, at 12:24 PM, the ADON verified there was no care plan in place for Resident 25's use of an anticoagulant.During a concurrent interview and record review of Resident 25's Care Plans, with the Director of Nursing (DON), on 9/25/25, at 2:53 PM, the DON acknowledged the importance of developing a care plan for the use of anticoagulants to ensure Resident 25 was being monitored for discoloration, bleeding, and bruising. The DON stated if the care plan was not in place, the side effects would be overlooked.b. A review of Resident 25's admission Record, indicated Resident 25 was readmitted to the facility on [DATE] with diagnoses including muscle weakness, unsteadiness on feet, hemiplegia (paralysis or weakness on one side of the body) affecting right dominant side, other muscle spasm (involuntary contractions of a muscle), and history of falling.A review of Resident 25's MDS dated [DATE], indicated Resident 25's cognitive skills for decision making were intact. The MDS indicated Resident 25 had upper extremity impairment on one side of the body and lower extremity impairment on both sides of the body. The MDS further indicated Resident 25 had a fall in the last month prior to admission, and a fracture related to a fall in the six months prior to admission.A review of Resident 25's Care Plan titled Fall Risk dated 8/8/25, indicated interventions including floor mat to the left side to prevent injury.During an observation on 9/23/25, at 8:36 AM, in Resident 25's room, there was no floor mat observed on the left side of Resident 25's bed. Resident 25 was observed with a fall risk band on the right wrist. During a concurrent observation and interview with Resident 25, on 9/24/25, at 8:19 AM, in Resident 25's room, there was no floor mat observed on the left side of Resident 25's bed. Resident 25 stated Resident 25 had not had floor mats since admission.During a concurrent observation and interview with Licensed Vocation Nurse 4 (LVN 4), on 9/24/25, at 8:40 AM, LVN 4 identified Resident 25 as a fall risk and verified Resident 25 did not have a floor mat on the left side of the bed. LVN 4 stated it would be important for Resident 25 to have the floor mat in place to prevent falls and injury.During a concurrent interview and record review with the DON, on 9/25/25, at 2:45 PM, the DON stated a floor mat should have been in place on the left side of Resident 25's bed, as outlined in Resident 25's fall risk care plan. The DON confirmed the intervention had not been implemented as required and acknowledged that failing to follow the care plan placed Resident 25 at safety risk and risk for potential injury.A 555494 Page 2 of 9 555494 11/25/2025 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0656 Level of Harm - Minimal harm or potential for actual harm review of the facility's policy and procedure (P&P) titled, Care Planning - Interdisciplinary Team, undated, indicated comprehensive, person-centered care plans are based on resident assessments.A review of the facility's policy and procedure (P&P) titled, Falls, undated, indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Cross reference to F689. Residents Affected - Few 555494 Page 3 of 9 555494 11/25/2025 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings: a. A review of Resident 22's admission Record, indicated Resident 22 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), diabetes (a long term condition that causes high blood sugar levels), and paraplegia (loss of voluntary movement and/or sensation in the lower body, including the legs, caused by damage to the spinal cord) among others. During a concurrent observation and interview with Resident 22, on 9/22/25, at 9:35 AM, inside Resident 22's room, the cover for both armrests of Resident 22's wheelchair were observed peeled off, exposing the underlying cushion. The edges of the peeled off cover had rough and uneven surfaces. Resident 22 stated the armrest cover started peeling off six months ago. A review of Resident 22's Care Plan Report titled, .AT RISK for impairment in skin integrity r/t [related to] fragile skin., dated 8/26/21, indicated .Identify/document potential causative factors and eliminate/resolve where possible. During an interview with the Director of Rehabilitation Services (DOR), on 9/24/25, at 11:14 AM, the DOR stated the armrests of a wheelchair were high-contact points and residents used them for mobility purposes and to rest their arms. The DOR stated a torn cover of the armrest could potentially cause skin issues like abrasions and skin tears. During a concurrent interview and record review with the DON, on 9/26/25, at 3:00 PM, the facility's policy and procedure (P&P) titled, Compliance Risks-Resident Quality of Care and Quality of Life, dated January 2025, was reviewed. The P&P indicated, .Policy Interpretation and Implementation.2. The following quality of care/quality of life standards are recognized as high-risk areas and therefore are carefully monitored.Resident Safety.4. Residents are provided with a safe, clean, and comfortable environment that is free of accident hazards, and adequately supervised. The DON stated the armrest on Resident 22's wheelchair should have been in good working condition, and further stated the facility's policy was not followed. b. A review of Resident 17's admission Record, indicated Resident 17 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease (a progressive brain disorder affecting movement) and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a stroke. During an observation on 9/22/25, at 4:14 PM, in Resident 17's room, Resident 17 was observed in bed and there was no floor mat present. 555494 Page 4 of 9 555494 11/25/2025 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview with Licensed Vocational Nurse 3 (LVN 3), on 9/22/25, at 4:20 PM, in Resident 17's room, LVN 3 verified Resident 17 did not have a floor mat on the right or left side of the bed. During an observation and interview with Registered Nurse 1 (RN 1), on 9/22/25, at 4:28 PM, in Resident 17's room, RN 1 verified there was no floor mat on the floor next to Resident 17's bed. RN 1 stated a floor mat should be placed just below the bed to protect a resident from injury from a fall. A review of Resident 17's order entry, dated 8/15/25, indicated right floor mat to prevent injury in case of fall. A review of Resident 17's care plan for risk for falls, dated 9/22/25, indicated Fall mat while resident in bed to reduce risk of injury. During an interview with the Assistant Director of Nursing (ADON), on 9/24/25, at 10:40 AM, the ADON stated the purpose of floor mats was to protect residents in case of a fall, so they would not have major injuries from the fall. The ADON stated if the floor mat was ordered at the right side of the bed, it should be at the right side to protect Resident 17. During a concurrent interview and record review of Resident 17's order entry, dated 8/15/25, with the Director of Nursing (DON), on 9/25/25, at 3:38 PM, the DON verified there was an order for a right-side floor/fall mat for Resident 17. The DON stated the physician order was not followed and implemented. c. A review of Resident 25's admission Record, indicated Resident 25 was readmitted to the facility on [DATE], with diagnoses including muscle weakness, unsteadiness on feet, hemiplegia (paralysis or weakness on one side of the body) affecting right dominant side, other muscle spasm (involuntary contractions of a muscle), and history of falling.A review of Resident 25's Minimum Data Set (MDS – a standardized assessment tool), dated 8/15/25, indicated Resident 25's cognitive skills for decision making were intact. The MDS indicated Resident 25 had upper extremity impairment on one side of the body and lower extremity impairment on both sides of the body. The MDS further indicated Resident 25 had a fall in the last month prior to admission and a fracture related to a fall in the six months prior to admission. A review of Resident 25's Care Plan titled Fall Risk, dated 8/8/25, indicated interventions including a floor mat to left side to prevent injury. A review of Resident 25's Order Summary Report, dated 9/24/25, indicated an order on 9/23/25 for a floor mat to the left side of Resident 25's bed to prevent injury. During an observation on 9/23/25, at 8:36 AM, in Resident 25's room, there was no floor mat observed on the left side of Resident 25's bed. Resident 25 was observed with a fall risk band on the right wrist. During a concurrent observation and interview with Resident 25, in Resident 25's room, on 9/24/25, at 8:19 AM, there was no floor mat observed on the left side of Resident 25's bed. Resident 25 stated Resident 25 had not had floor mats since admission.During a concurrent observation and interview with LVN 4, in Resident 25's room, on 9/24/25, at 8:40 AM, LVN 4 identified Resident 25 as a fall risk and verified Resident 25 did not have a floor mat on the left side of the bed. LVN 4 stated it would be important for Resident 25 to have the floor mat in place to prevent falls and injury. 555494 Page 5 of 9 555494 11/25/2025 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0689 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the DON, on 9/25/25, at 2:45 PM, the DON stated a floor mat should have been in place on the left side of Resident 25's bed in accordance with the physician's order dated 9/23/25 and Resident 25's fall risk care plan dated 8/8/25. The DON acknowledged the intervention was not implemented as required and confirmed the absence of the floor mat placed Resident 25 at increased risk of potential injury. Residents Affected - Few A review of the facility's policy and procedure (P&P) titled, Falls, undated, indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Cross reference to F656. 555494 Page 6 of 9 555494 11/25/2025 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings:A review of Resident 84's admission Record (a document containing a summary of basic information about the resident), indicated Resident 84 was admitted to the facility on [DATE] and readmitted to the facility on [DATE].A review of Resident 84's Minimum Data Set (MDS- a standardized assessment tool), dated 9/10/25, indicated Resident 84's cognitive (ability to think and reason) skills for decision making were intact. The MDS indicated Resident 84 had no natural teeth.A review of Resident 84's Treatment Sheet, dated 6/19/25, indicated a Treatment Plan including a referral for new dentures.A review of Resident 84's Care Plan titled Dental Status, dated 9/16/25, indicated interventions including to coordinate arrangements for dental care and to monitor/document/report any signs and symptoms of oral/dental problems needing attention.A review of Resident 84's Order Summary Report, dated 9/24/25, indicated orders for regular diet easy to chew texture and dental evaluation and treatment as indicated.During a concurrent observation and interview with Resident 84, in Resident 84's room, on 9/22/25, at 10:20 AM, Resident 84 was observed with no natural teeth. Resident 84 stated Resident 84 had dentures at the previous facility, but the current facility did not ask about dentures upon admission. Resident 84 stated it was difficult for Resident 84 to chew at times, and the staff must give Resident 84 chopped food, despite being on a regular diet. Resident 84 further stated Resident 84 would like to get new dentures.During a concurrent interview and record review with the Social Services Director (SSD), on 9/25/25, at 8:49 AM, the SSD verified Resident 84 did not have a referral for dental services after readmission. The SSD stated it was the responsibility of the SSD to complete and follow up on Resident 84's dentures and it should have been done. The SSD stated it was important to follow up on dental services for eating and dignity purposes.A review of the facility's Policy and Procedure (P&P), titled Dental Services, undated, indicated . Social services will assist residents with appointments and arrangements as needed . Lost or damaged dentures will be addressed per regulatory requirements. Residents Affected - Few 555494 Page 7 of 9 555494 11/25/2025 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based 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. Findings: Residents Affected - Few 1. During an observation on 9/22/25, at 9:15 AM, in the bathroom between the rooms of Resident 6 and Resident 20, a gray basin containing food containers and utensils was found on the floor. During a concurrent observation and interview with Certified Nurse Assistant 1 (CNA 1), on 9/22/25, at 12:55 PM, CNA 1 was asked about the contents of the gray bin and stated there were four food containers and two forks. CNA 1 stated this was not common practice and these items should not be kept on the bathroom floor. During a concurrent interview and record review, with the Infection Preventionist (IP), on 9/26/25, at 3:15 PM, IP was asked if finding food containers and utensils on the bathroom floor in a resident's room was an expectation. IP stated it was not an expectation. IP added that she expected her staff to follow infection control protocols. The facility's policy and procedure (P&P) titled, Infection Prevention and Control Program was reviewed with the IP. The P&P indicated, an Infection Prevention and Control Program is established and maintained to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. IP acknowledged the staff did not follow the policy when food containers were found on the floor. 2. A review of the facility census dated 9/21/2025, indicated Resident 58 was on Enhanced Barrier Precautions (EBP- an infection control precaution utilized to prevent the spread of multi-drug-resistant infectious disease to residents). During a concurrent observation and interview on 9/22/25, at 9:23 AM, RT 1 was observed putting on gloves upon entering Resident 58's room. RT 1 then changed a used yankauer (a handheld suction tip used in medical settings to clear secretions like blood and saliva from the airway or surgical sites) with a new one and exited the room. Then, RT 1 removed the gloves. RT 1 did not do hand hygiene after stepping out of the room or after removing the gloves. RT 1 stated the expectation was to do hand hygiene before and after entering a resident's room. RT 1 stated he did not do hand hygiene when he stepped out of Resident 58's room. During an interview with the IP on 9/26/25, at 3:26 PM, the IP stated Resident 58 was on EBP and the expectation was for staff to practice standard precautions (basic infection control practices in healthcare setting that includes hand hygiene and appropriate use of protective equipment) when entering and exiting the room if they did not provide high-contact resident care. The IP further stated RT 1 should have practiced hand hygiene upon entering and exiting Resident 58's room.A review of the facility's policy and procedure titled, Enhance Barrier Precautions, revised December 2024, indicated, .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 15. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. 3. During observations on 9/22/25, at 12:58 PM, the following were observed: 555494 Page 8 of 9 555494 11/25/2025 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a. The trash bin in Resident 12's room was full and overflowing.b. The trash bin in Resident 20's room was full and overflowing.c. The trash bin in Resident 88's room was full and overflowing. During a concurrent interview and record review with the IP on 9/26/25, at 3:26 PM, the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revision date December 2023, was reviewed. The P&P indicated, . Policy Statement. An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IP stated the overflowing trash bins were not consistent with maintaining a safe and sanitary environment. 555494 Page 9 of 9