Inspection Reports for Cedar Mountain House
11 Sherwood Ridge Road Brevard, NC 28712, Brevard, NC, 28712
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 29, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 05/28/25 to 05/29/25 to assess compliance with medication administration and other regulatory requirements.
Findings
The facility failed to administer medications as ordered by a licensed practitioner for two residents, resulting in a Type B Violation related to medication administration errors and failure to follow medication orders, including missed doses of budesonide and Symbicort, and failure to discontinue a vitamin supplement as ordered.
Deficiencies (3)
Failure to administer budesonide as ordered for Resident #7, resulting in increased risk of breathing difficulties and shortness of breath.
Failure to administer Symbicort as ordered for Resident #2 due to medication unavailability.
Failure to discontinue Preservision AREDS2 vitamin supplement for Resident #2 as ordered by the primary care provider.
Report Facts
Medication error rate: 4
Medication administration occurrences: 59
Medication administration occurrences: 57
Medication administration occurrences: 54
Medication administration occurrences: 52
Inspection Report
Capacity: 64
Deficiencies: 17
Date: Apr 30, 2025
Visit Reason
The facility was surveyed for conformance with the 1996 Rules for the Licensing of Adult Care Homes, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina Building Code for Institutional Unrestrained Occupancies as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including lack of emergency release switches on electromagnetic locks, missing wiring diagrams, obstructed courtyard exit, missing fire and building safety inspection reports, corridor obstructions, missing wanderer alarms, housekeeping and maintenance issues, unsafe storage of oxygen bottles, missing towel bars, malfunctioning emergency lighting and exit signs, plumbing issues, fire safety equipment deficiencies, and inadequate exhaust ventilation.
Deficiencies (17)
Emergency release switch missing within 3 feet of electromagnetic lock door between Memory Care and Lobby.
No wiring diagram or system components location map adjacent to fire alarm panel.
Courtyard gate equipped with padlock but staff did not carry keys to release gate in emergency.
Facility did not maintain current fire sprinkler inspection report available for review.
Corridors obstructed by equipment including box and wheelchair in stairwell by Room 128.
Exit door by stair Room 210 not equipped with working sounding device to alert staff.
Walls, ceilings, and floors not kept clean and in good repair with multiple specific damages noted.
Oxygen bottles improperly stored unsecured in Rooms 123 and 133.
Bedrooms or adjoining bathrooms not equipped with towel bars for each resident; specifically Room 218 Bath.
Electrical emergency/safety lighting equipment not maintained in safe operating condition; multiple emergency lights and exit signs failed to illuminate on test.
Plumbing piping not installed with minimum 2" air gap; icemaker drain line improperly positioned.
Fire safety equipment not inspected or maintained; kitchen hood suppression system inspection overdue.
Fire resistant rated ceiling penetrations with missing or dropped escutcheon rings leaving gaps.
Fire safety doors in hazardous areas missing closers or closers disabled, preventing automatic closing and latching.
Unapproved devices used to keep doors open, preventing proper closing and latching.
Mechanical equipment not maintained in safe operating condition; rooftop equipment wrapped in blue tarp.
Facility did not maintain exhaust ventilation in specified spaces including common areas and laundry room.
Report Facts
Total licensed beds: 64
Dates of plan of correction completion: Multiple corrective actions planned with completion dates ranging from 05/24/2025 to 06/23/2025.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 31, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation from 01/30/24 to 01/31/24, initiated by the Transylvania County Department of Social Services on 01/10/24.
Complaint Details
Complaint investigation was initiated by the Transylvania County Department of Social Services on 01/10/24 related to personal care and health care follow-up issues.
Findings
The facility failed to provide personal care according to a resident's care plan related to limited assistance with bathing, failed to ensure referral and follow-up for acute health care needs for two residents including tooth pain and delayed physical therapy, and failed to serve therapeutic diets as ordered for one resident.
Deficiencies (3)
Failed to provide personal care according to Resident #5's care plan related to limited assistance with bathing.
Failed to ensure referral and follow-up to meet acute health care needs for Residents #1 and #2 related to tooth pain not reported to PCP and delay in physical therapy after amputation.
Failed to ensure therapeutic diets were served as ordered for Resident #8 who had a physician's order for a mechanical soft meats only ground diet.
Report Facts
Showers or baths received: 13
Shower frequency: 2
Delay in physical therapy: 5
Pain level: 10
Pain level constant: 4
Inspection Report
Annual Inspection
Census: 35
Capacity: 64
Deficiencies: 6
Date: Nov 16, 2023
Visit Reason
The Adult Care Licensure Section and the Transylvania Department of Social Services completed an annual survey from 11/14/23 to 11/16/23.
Findings
The facility was found deficient in multiple areas including failure to ensure CPR certified staff on night shifts, inadequate staffing hours resulting in unmet resident care needs, incomplete and unsigned care plans, failure to serve therapeutic diets as ordered, and failure to administer medications as prescribed, including critical glaucoma medications.
Deficiencies (6)
Facility failed to ensure at least one staff person on night shift was CPR certified for 9 of 14 shifts from 11/01/23 through 11/14/23.
Facility failed to ensure required staffing hours were met during 11 shifts based on a census of 35 residents from 10/25/2023 through 11/09/2023, resulting in residents not getting showers, hydration, snack passes, and timely personal hygiene.
Facility failed to ensure 2 of 5 sampled residents had care plans completed within 30 days of admission and updated annually.
Facility failed to ensure 2 of 5 sampled residents had care plans signed by a physician within 15 days of completion.
Facility failed to ensure 1 of 4 sampled residents was served physician ordered therapeutic diet of mechanical soft with ground meats.
Facility failed to ensure medications were administered as ordered for 5 of 5 sampled residents, including glaucoma eye drops, anxiety, insomnia, heart attack and stroke prevention, anxiety and depression, and high cholesterol medications.
Report Facts
Shifts with inadequate CPR certified staff: 9
Shifts with inadequate staffing hours: 11
Residents sampled: 5
Residents with incomplete care plans: 2
Residents with unsigned care plans: 2
Residents with medication administration issues: 5
Facility licensed capacity: 64
Facility census: 35
Inspection Report
Capacity: 64
Deficiencies: 11
Date: Mar 13, 2019
Visit Reason
The facility was surveyed for conformance with the 1996 Rules for the Licensing of Adult Care Homes, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina Building Code for Institutional Unrestrained Occupancies as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including failure to meet building code requirements for exits, lack of current sanitation and fire safety inspection reports, obstructions in corridors, poor housekeeping and maintenance issues, unsafe electrical and mechanical equipment, plumbing safety device failures, improper hot water temperatures, and inadequate exhaust ventilation in required areas.
Deficiencies (11)
Exterior courtyard gate has a padlock and staff do not carry keys; keys are located in the Business Office.
Facility did not maintain current sanitation, fire, and building safety inspection reports.
Corridors were not maintained free of obstructions; six chairs restricted corridor width to less than required 6 feet clearance.
Walls, ceilings, and furnishings were not kept clean and in good repair, including peeling wallpaper, cracked finishes, loose door hinges, and damaged doors.
Facility was not maintained free of hazards; broken and loose floor tile in Room 127 Bath created a trip hazard.
Electrical emergency/safety lighting equipment was not maintained in safe operating condition; multiple emergency lights failed to illuminate or had loose bulbs.
Failure to maintain fire resistant enclosures and self-closing doors; broken door closer in HVAC Room.
Plumbing equipment not maintained in safe and operating condition; wall mounted sink not secure in Room 139 Bath.
Failure to install and maintain required plumbing safety devices; shower wands in Serenity Spa and Room 208 Bath lacked vacuum breakers.
Hot water temperature exceeded maximum allowed; water temperature at hair washing sink in Beauty Salon was 135 degrees Fahrenheit.
Facility did not provide exhaust ventilation in required areas; exhaust fans in Clean Linen and Second Floor Staff Bath were not working.
Report Facts
Total licensed beds: 64
Corridor clearance: 6
Water temperature: 135
Inspection dates: 2017
Inspection dates: 2017
Inspection dates: 2018
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 17, 2018
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on October 17, 2018 through October 18, 2018.
Findings
The facility failed to ensure therapeutic diets were served as ordered for 1 of 1 sampled residents (Resident #5) regarding pureed diet orders. Resident #5 was served regular vegetables instead of pureed vegetables as ordered, due to staff unawareness and conflicting diet orders.
Deficiencies (1)
Failed to ensure therapeutic diets were served as ordered for Resident #5 regarding pureed diet orders.
Inspection Report
Capacity: 64
Deficiencies: 7
Date: Jan 25, 2017
Visit Reason
The facility was surveyed for conformance with the 1996 Rules for the Licensing of Adult Care Homes, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina Building Code for Institutional Unrestrained Occupancies during a Construction Section Biennial Survey.
Findings
The inspection identified deficiencies including outdated sanitation and fire safety inspection reports, housekeeping hazards such as covered fire detection devices and improper ice machine drain connections, incomplete fire safety rehearsal records, compromised fire-rated walls and ceilings with unsealed holes, missing sprinkler escutcheon, and corridor doors that could not resist fire and smoke passage due to holes.
Deficiencies (7)
Most recent sanitation inspection for the building and kitchen was dated 2013; annual inspections required.
Smoke detector and 3 sprinkler heads covered with tape at ceiling repair; corrected onsite.
Ice machine drain line directly connected to wall drain without required 2-inch elevation, risking contamination.
Fire safety rehearsal records lacked list of staff present and description of rehearsal activities.
One-hour fire rated walls and ceilings compromised with unsealed holes and poorly repaired gypsum board.
Sprinkler escutcheon missing in soiled linen area.
Corridor doors had holes at latchsets, unable to resist passage of fire and smoke.
Report Facts
Total licensed capacity: 64
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 28, 2016
Visit Reason
The Adult Care Licensure Section completed an on-site annual and follow-up survey and a complaint investigation on 6/21/16, 6/22/16, and 6/27/16 with a telephone exit on 6/28/16.
Complaint Details
Complaint investigation included concerns about the accuracy of Resident #1's assessment and care plan, and failure to provide requested medical records to Resident #1 and her guardian.
Findings
The facility failed to assure an accurate functional assessment for one resident, failed to provide a reasonable response to requests for medical records for one resident and her guardian, and failed to ensure two medication aides completed the required competency examination within 60 days of hire.
Deficiencies (3)
Failed to assure an accurate functional assessment was completed for Resident #1 related to blood pressure and blood sugar monitoring, ambulation and the use of assistive devices, shortness of breath upon exertion, limited strength, peripheral neuropathy, pedal edema, diet order, and urinary incontinence.
Failed to assure Resident #1 and her guardian received a reasonable response to requests for medical information and copies of medical records.
Failed to assure 2 of 4 medication aides successfully completed the medication competency examination within 60 days of hire as a medication aide.
Report Facts
Dates of survey: 2016-06-21 to 2016-06-28
Resident #1 admission date: Mar 16, 2012
Guardianship date: Jun 8, 2016
Medication Aide Staff D hire date: Feb 23, 2016
Medication Aide Staff E hire date: Apr 1, 2016
Medication Aide competency exam due date Staff D: Apr 23, 2016
Medication Aide competency exam due date Staff E: Jun 1, 2016
Medication Aide exam scheduled date Staff D: Jul 6, 2016
Medication Aide exam scheduled date Staff E: Aug 4, 2016
Correction due date: Aug 12, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Aide | Failed to complete medication competency exam within 60 days of hire |
| Staff E | Medication Aide | Failed to complete medication competency exam within 60 days of hire |
| Resident Care Coordinator | Responsible for filling out Resident #1's Service Plan and scheduling medication aide exams | |
| Administrator | Informed Resident #1 and guardian about company policy for medical records release |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 14, 2015
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on May 14, 2015, initiated by the county Department of Social Services on May 6, 2015.
Complaint Details
Complaint was initiated by the county Department of Social Services on May 6, 2015, regarding bedbug infestations in the facility. The investigation confirmed ongoing bedbug issues and treatment efforts.
Findings
The facility failed to maintain a clean environment free of hazards related to bedbug infestations in multiple rooms (203, 204, 205, 206, and 208). The new pest control company began treatment on May 11, 2015, and the facility was actively monitoring and treating the infestation with staff training and ongoing inspections.
Deficiencies (1)
Facility failed to maintain a clean environment free of hazards related to bedbug infestations in Rooms 203, 204, 205, 206, and 208.
Report Facts
Date of survey: May 14, 2015
Date complaint initiated: May 6, 2015
Number of rooms with bedbug infestations: 5
Duration of employment: 6
Duration of employment: 6
Duration of employment: 1
Date treatment began: May 11, 2015
Date new pest control company verified bedbug issue: May 1, 2015
Date residents moved rooms: May 13, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper | Reported observing several bedbugs and described treatment preparations in Rooms 203 and 205 | |
| Maintenance Director | Reported ongoing bedbug problem and treatment schedule | |
| Technician from new pest control company | Described treatment methods and confirmed bedbug presence in multiple rooms | |
| Staff A | Personal Care Aide | Reported knowledge of bedbug issues and observations of extermination activities |
| Staff B | Personal Care Aide/Medication Aide | Reported seeing one bedbug in Medication Room and efforts to fix problem |
| Staff C | Medication Aide | Reported recent bedbug sightings and new pest control company involvement |
| Administrator | Reported monitoring efforts, communication with exterminator, and staff training | |
| Regional Director of Operations | Reported notification of bedbug issue and contract with new exterminator company |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 7, 2014
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation on November 4-7, 2014.
Complaint Details
The visit included a complaint investigation triggered by concerns about bedbug infestation and medication administration issues.
Findings
The facility failed to maintain a clean environment free of hazards related to a bedbug infestation in Room 204, failed to assure referral and follow-up to meet acute care needs related to falls and medication administration, and failed to assure medications were administered within one hour before or after the prescribed time for multiple residents.
Deficiencies (4)
Failed to maintain a clean environment free of hazards related to a bedbug infestation in Room 204.
Failed to assure referral and follow-up to meet acute care needs of residents related to falls and medication administration.
Failed to assure medications were administered within one hour before or after the prescribed time for scheduled multi-dose time sensitive medications for multiple residents.
Failed to assure non-disposable place settings were used for residents; styrofoam plates and bowls were used regularly.
Report Facts
Medication administration occurrences outside time frame: 19
Medication administration occurrences outside time frame: 62
Medication administration occurrences outside time frame: 43
Medication administration occurrences outside time frame: 11
Medication administration occurrences outside time frame: 5
Medication administration occurrences outside time frame: 4
Medication administration opportunities: 92
Medication administration opportunities: 177
Medication administration opportunities: 31
Medication administration opportunities: 61
Medication administration opportunities: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Interviewed regarding bedbug infestation and medication pass challenges. | |
| Medication Aide | Interviewed regarding medication pass and timing issues. | |
| Resident Care Coordinator | Interviewed regarding medication administration and resident falls. | |
| Executive Director | Interviewed regarding bedbug infestation and facility management. | |
| Dietary Manager | Interviewed regarding use of Styrofoam plates and bowls. | |
| Health Department employee | Conducted inspection of Room 204 for bedbugs. | |
| Maintenance Director | Interviewed regarding bedbug infestation and pest control. | |
| Housekeeper | Interviewed regarding cleaning procedures and bedbug infestation. | |
| Supervisor | Interviewed regarding medication issues and insurance authorization. |
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