Cedar Hill Healthcare and Rehabilitation Center

Inspectors wroteBased on review of facility policy, observations and staff and resident interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining an acceptable water temperature for two of three units (North Unit and South Unit). Findings Include: Review of the facility policy Resident Environment last reviewed 2/16/26, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. Review of the facility policy Water Temperature last reviewed 2/16/26, indicates water distribution systems shall be designed and arranged to provide potable hot and cold water at hot and cold-water outlets at all times. Review of the facility provided grievance log on 4/28/26, revealed two concerns about the hot water temperatures. On 2/25/26, a resident filed a concern about the hot water temperatures. [...]

Inspectors wroteBased on a review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident representative of the start of a new antibiotic for one of three residents (Resident R136).

Inspectors wroteBased on review of facility policy, clinical record, facility documents, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of neglect for one of three residents (Resident R2).

Inspectors wroteBased on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for two of three residents (Resident R4 and R84).

Inspectors wroteBased on facility policy, clinical records and staff interview, it was determined that the facility failed to develop a care plan for two of three residents (Resident R1 and R97) to accurately reflect the current status of the resident.

Inspectors wroteBased on review of facility policies, resident record review, and staff interviews, it was determined that the facility failed to follow professional standards of practice when obtaining physician orders for one of four residents. (Resident R136).

Inspectors wroteBased on observation, staff interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide appropriate assistance with meals for one of three residents (Resident R65).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to provide care and treatment as ordered by physician for one of three residents (Residents R2) and have a physician order for a continuous glucose monitoring device for one of one resident (Resident R97).

Inspectors wroteBased on review facility policies, observations, clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of an indwelling urinary catheter as required for one of three residents (Resident R134).

Inspectors wroteBased on review of clinical records, facility policy and staff and interviews it was determined the facility failed to ensure resident's receiving dialysis received care and treatment as ordered and ensured fluid restrictions were maintained for one of two residents (Resident R6).

Inspectors wroteBased on resident record review and staff interviews, it was determined to facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents (Resident R73).

Inspectors wroteBased on review of the facility policy, the facility's tray assembly tickets, observation, and resident and staff interviews, it was determined that the facility failed to follow their tray assembly tickets for preferences for two of five residents (Resident R11 and R124).

Inspectors wroteBased on review of facility policy, review of resident council meeting minutes, review of grievance logs, observations, staff and resident interviews it was determined that the facility failed to accommodate the call bell needs for four of nine residents (Resident R2, R3, R4 and R7)

Inspectors wroteBased on review of facility policy, resident clinical records, observations, and staff interviews, it was determined that the facility failed to use Personal Protective Equipment (PPE) appropriately, which created the potential for the cross-contamination and the spread of diseases and infections in two out of 18 droplet precautions (infection control measures designed to prevent the spread of infectious diseases that are transmitted through respiratory droplets) rooms. (Covid and Exposed Unit).

Inspectors wroteBased on review of facility policy, observations, and staff interview it was determined that the facility failed to provide privacy and confidentiality of resident healthcare information for twelve of thirty-seven residents (Residents R3, R28, R33, R57, R76, R81, R94, R117, R122, R123, R131 and R435).

Inspectors wroteBased on review of facility policies, observations and staff interview it was determined that the facility failed to the failed to ensure medications were not left unattended at the bedside for three of three of seven residents (Residents R36, R50 and R98).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain call bells were in reach for two of seven residents as required (Resident R30 and R108).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to assure physician orders, residents' Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments), was available for one of four residents (Residents R336).

Inspectors wroteBased on review of resident clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of two residents (Resident R41, and R107). Findings Include: A review of the facility policy Documentation of Discharges or Deaths last reviewed 4/17/24, indicated all discharges will be sent to the Office Ombudsman's office at the end of the month. [...]

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to provide care and services according to accepted standards of clinical practice in the identification of a resident's diagnosis of schizoaffective disorder for one of five residents (Resident R45).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one out of three sampled residents (Closed Resident Record CR132).

Inspectors wroteBased on facility policy, clinical record review, and interview, the facility failed to have physician order specifications relating to size of indwelling catheter for one of three residents (Residents R103).

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain physician's orders, conduct ongoing accurate assessments and failed to obtain a consent to ensure that enabler/side rail assist bars were used to meet residents' needs and the risks associated with enabler bar/side rail assist bar usage for two of three residents (R30 and R75).

Inspectors wroteBased on review of facility policy, Nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff received annual in-service education for one out of six nursing personnel (Registered Nurse Employee E5).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of of three residents (Resident R385).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to properly disinfect a respiratory equipment spacer (spacer- a plastic tube with a mouthpiece on one end, allows the person more time to inhale allowing medication to enter the lungs more efficiently) prior to placing in medication cart for one of three residents (Resident R136) and failed to prevent cross contamination during a dressing change for one of three residents (Resident R90). Findings Include: Review of the Aero Chamber Z STAT manual cleaning instructions for mask and mouthpiece chambers indicate: -Soak the parts for 15 minutes in a mild solution of liquid dish detergent and lukewarm clean water. -Agitate gently. -Rinse parts in clean water. -Dishwasher safe, avoid heated dry over 158*, parts on top rack only. -Do not boil or sterilize. [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of two resident hospital transfers (Residents R41 and R107). Findings Include: Review of the facility Transfer Notice of Bed Hold Policy and Readmission policy dated 4/17/24, indicated the facility will provide written information to the resident or legally responsible party that specifies the bed-hold policy prior or at the time of transfer to a hospital or other anticipated temporary leave. [...]

Inspectors wroteBased on review of facility policy, clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds and closed account upon discharge or death in a timely manner for one of five resident records reviewed. (Resident R1).

Inspectors wroteBased on review of facility policy, resident council meeting minutes and resident and staff interviews, it was determined that the facility failed to provide evidence that Resident Council concerns were assigned to the appropriate department, facility responses to Resident Council concerns, and how the facility resolved the repetitive Resident Council concerns for three of three months (January, February, and March 2024).

Inspectors wroteBased on review of facility policy and investigative documents, it was determined that the facility failed to provide quality of care with an unlicensed employee providing medications to six residents. This was identified as a past non-compliance for six of six residents (Resident R1, R2 R3, R4, R5 and R6).

Inspectors wroteBased on policy review, observations, and staff interview, it was determined that the facility failed to maintain a clean, comfortable, homelike environment in five out of 12 sampled resident rooms (Residents R2, R5, R6, R7, and Resident R8).

Inspectors wroteBased on review of facility documentation, observations, resident interview and staff interviews it was determined that the facility failed to consistently maintain functional telephone services and uphold residents' ability to communicate with individuals for two out of four observed resident phones (Resident R1 and Resident R2).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to secure confidential medical information on staff computers for two out of seven medication carts (300 hall/Sub-acute and 100 hall/South).

Inspectors wroteBased on a review of vendor invoices, facility financial documents, as well as interviews with vendors and staff, it was determined that facility failed to pay bills in a timely manner which created a potential for an interruption of supplies and services.

Inspectors wroteBased on a review of vendor invoices, facility financial documents, as well as interviews with vendors and staff, it was determined that the governing body failed to implement policies regarding the management of the operation of the facility by failing to respond to vendor invoices and failing to respond to facility requests for payment of outstanding bills.

Inspectors wroteBased on facility document review, observation, and staff interview, it was determined that the facilityfailed to provide an ongoing activity program to meet the needs of the residents by failing to respond to facility requests for supplies and by failing to respond vendor invoices which caused entertainment activities to be canceled and refusals of entertainers to return to the facility.

Inspectors wroteBased on review of infection control documentation and staff interview, it was determined that the facility failed to have one or more individuals serving as the Infection Preventionist for seven of twelve months (November 2022, December 2022, January 2023, June 2023, July 2023, August 2023, and September 2023).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for 16 of 19 new admissions in the past 30 days.

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly and securely store medications in two out of four medications carts (South and Subacute).

Inspectors wroteBased on review of facility documentation, resident and staff interviews, and review of facility policy the facility failed to make certain that all residents had the access/ability to file a grievance, that the facility documented a residents grievance, and that the facility had a policy and procedure that met federal guidelines for one of six residents (Resident R71).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing a two-person transfer per physician's order for one of six sampled residents (Resident R13).

Inspectors wroteBased on review of clinical records and facility investigative documents, and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation (the act of stealing something that you have been trusted to care of and using it for yourself) of medications for one of five residents reviewed (Residents R216).

Inspectors wroteBased on review of facility policy, clinical record review, investigation documentations, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse for one of six sampled residents (Resident R13).

Inspectors wroteBased on a review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for three of 13 residents (Resident R28, R51, and R85).

Inspectors wroteBased on review of facility policy, clinical records and staff interview it was determined that the facility failed to implement comprehensive care plans for one of six clinical records reviewed (Resident R98).

Inspectors wroteBased on review of clinical records, and staff interview the facility failed to update and revise care plans for one of six residents reviewed (R98).

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to assess, stage and size a residents wound at admit for one of four Residents reviewed (Resident R105).