Cedar Hill Healthcare Center

Inspectors wroteBased on observation, record review and interview, the facility failed to provide adequate supervision for 1 (Resident#1) of 8 residents reviewed for supervision. The facility failed to ensure Resident #1 had adequate supervision on Saturday 07/19/25 for approximately 30 minutes. Resident#1 left out the front door and wheeled himself across 4 lanes (with two lanes that ran in the opposite direction) of traffic across the street to the gas station unsupervised. These failures could place residents' health and safety at risk. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/19/25 and ended on 07/31/25 the facility had corrected the non-compliance before the state's investigation began.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure food items were properly stored in the facility freezer on 06/30/25. These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents toileting facilities were adequately equipped to allow residents to call for assistance for 5 Residents (Resident#13, Resident#16, Resident#57, Resident#63, and Resident#87) of 20 residents reviewed for residents' call systems. The facility failed on 06/30/2025 to ensure the call light system was accessible to a resident, lying on the floor in the shared residents' toilets located inside the residents' rooms when the call lights were missing the pull strings, for:. Resident#13. Resident#16 . Resident#57. Resident#63 . Resident#87 This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers.

Inspectors wroteBased on interview, observation and record review, the facility failed to make a comprehensive assessment of each residents' needs, strengths, goals, life history, and preferences within 14 calendar days after admission for 1 of 5 residents (Resident #31) reviewed for accuracy of assessments. The facility failed to accurately complete Resident #31's Quarterly Minimum Data Set assessment on 6/3/25 by not accounting for the falls on 4/18/25, 5/8/25, 5/16/25, 5/17/25, 5/21/25, 5/22/25 which occurred prior to her re-admittance to the facility on 6/2/25. This failure could place residents at risk of not having their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 residents (Resident#8, and Resident#63) reviewed for comprehensive care plans in that: The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #8's, and Resident#63's ADLs on the care plan revision dated 04/02/25. These deficient practices could place residents at risk of not receiving appropriate treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #8 and Resident #80) of 12 residents reviewed for ADLs. The facility failed on 06/30/2025 to ensure the following:1. Resident #8 had her fingernails trimmed.2. Resident #80 had fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 Resident (Resident #8) of 6 residents reviewed for foot care. The facility failed on 06/30/2025 and did not provide adequate foot care for Resident #8 who was also a diabetic and had a standing order for podiatric services. Resident #8's Toenails were chipped, thick, and long. This failure could put residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #41) resident reviewed for infection control. The facility failed on 06/30/2025 when CNA A failed to change gloves and perform hand hygiene when she went from dirty to clean during incontinence care for Resident #41. This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three of seven residents (Residents #2, #3, and #4) reviewed for accommodation of needs, in that: 1. The facility failed to ensure Resident #2's, and Resident #4's call lights were placed within their reach on 03/05/25. 2. The facility failed to ensure Resident #3's call light string was not obstructed by a mechanical lift sling which was placed on top of the call light string preventing Resident #3 to pull the string to activate the call light on 03/05/25. This failure could place residents at risk of injuries and unmet needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #1) resident reviewed for infection control. CNA A did not perform hand hygiene after providing incontinent care for Resident #1. This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse and exploitation for 1 of 3 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was protected from sexual abuse by Resident #2. Resident #2 was found in Resident #1's bed lying to top of Resident #1, both nude from the waist down and Resident #2 was observed to have his hand on Resident #1's vaginal area as he swayed his hips side to side. On 11/04/24 at 5:00 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/05/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food items in the facility freezer and preparation area had use-by date. 2. The facility failed to perform hand hygiene while preparing food for lunch service. 3. The facility failed to maintain sanitary conditions in the kitchen that was free of flies. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for two (End of Hall 100 shower room and Hall 200 shower room) of three shower rooms reviewed for physical environment. The facility failed to ensure shower rooms were clean for the end of hall 100 shower room and Hall 200 shower room. These failures could place residents at risk for a diminished quality of life and an unsanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #47, Resident #71, and resident #3) of 8 residents reviewed for quality of life. The facility failed to ensure: 1- Resident #47 had his fingernails cleaned and trimmed. 2- Resident #71 had her fingernails cleaned and trimmed. 3- Resident #3 had his fingernails cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 9.38 %, based on 3 errors of 32 opportunities, which involved two of six residents (Residents #23 and #39) and one (MA D) of four staff reviewed for pharmacy services. 1. The facility failed to ensure MA D administered Resident #23's Flonase allergy relief nasal suspension 50 mcg on 06/25/24 as ordered by the physician. 2. The facility failed to ensure MA D administered Resident #39's Namenda 5 mg and Polyethylene Glycol powder 17 gm on 06/25/24 as ordered by the physician. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on interview and record review, the facility to provide or obtain laboratory services to meet the needs of its residents for 1 (Resident #51) of 4 residents reviewed for labs. The facility failed to ensure labs for Depakote levels (used to monitor the level of Depakote) were not drawn monthly after December 2023 as ordered by the physician for Resident #51. This failure could place residents at risk for a delay in identifying or diagnosing a problem, adjusting medications, and ensuring treatment needs were identified and addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #22, Resident #34, and Resident #39) of eight residents reviewed for infection control. 1. The facility failed to ensure LVN E prevented cross contamination of a bottle of test strips used to obtain glucose levels when she carried the bottle of test strips into Resident #22's room and returned it to the medication cart without sanitizing it. 2. The facility failed to ensure CNA B and CNA C performed hand hygiene during incontinence care for Resident #34. 3. The facility failed to ensure MA D sanitized the blood pressure cuff between uses on Resident #34 and Resident # 39. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the facility's only kitchen, dining room and one of three halls (Hall 200) reviewed for pest control. The facility failed to keep an effective pest control program to ensure the kitchen, dining room, and residents' rooms were free of flies. This failure could place residents at risk for reduced quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to develop, implement, and maintain an effective training program for all existing staff, individuals providing services under a contractual arrangements and volunteers, consistent with their expected roles for 2 of 5 employees (CNA L and CNA M) reviewed for required trainings. The facility failed to ensure the new hire orientation training was completed for CNA L and CNA M. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for one of two (Resident #84) reviewed for quality of care. The facility failed to ensure the supplemental O2 was provided at the physician ordered rate for Resident #84. This failure could place residents who received oxygen therapy at risk of oxygen toxicity. Findings Included: Record review of Resident #84's admission MDS assessment dated [DATE], reflected an [AGE] year-old male admitted to the facility on [DATE]. He had a BIMS score of 9 which indicated he was moderately cognitively impaired. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for 5 (Resident# 40, Resident#43, Resident #72, Resident #139, and Resident #47) of 18 residents observed for medication administration and storage. The facility failed to ensure insulin pen was labeled with opening date. The facility failed to ensure a bottle of multivitamin gummies was not left unsupervised in Resident #40's room in security unit. The facility failed to ensure - clonazepam 2 tablets of Resident#43 and Resident #72 were both stored in one cup, -Eliquis 1 tablets of Resident # 139 were not left in MA A cart unlabeled, and -Resident #47 medication was popped at the right time and stored properly. This failure could place residents at risk of overmedication, misuse, adverse drug reactions, and not receiving the intended therapeutic effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for two (Residents #36 and #71) of 18 residents reviewed for dental services. The facility failed to assist in providing routine dental services for Resident #36 and #71. This failure could affect residents by placing them at risk for oral complications, dental pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for 10 of 10 pureed diets reviewed for nutritive value. The facility failed to ensure [NAME] L following the menu when preparing the pureed lunch meal. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 3 residents (Resident #7) reviewed for tube feeding. 1. LVN H failed to check for residual (the amount of fluid/contents that are in the stomach) for Resident #7 prior to initiating a bolus feeding (feeding method using a syringe to deliver formula through feeding tube) and failed to follow physician orders. 2. LVN H failed to ensure Resident #7's head was elevated at a minimum of 30-degree angle while receiving bolus feeding. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalizations.

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 7 of 35 days (01/21/23, 01/22/23, 01/29/23, 02/12/23, 02/19/23, 02/26/23, and 03/18/23) reviewed for nursing services. The facility failed to have RN coverage for eight consecutive hours for 7 days (Saturdays and Sundays) beginning 01/01/23 until 04/30/23. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest in two of two rooms (room [ROOM NUMBER] and #217) on Hall 200. The facility failed to ensure room [ROOM NUMBER] was free of roaches. The facility failed to ensure room [ROOM NUMBER] was free of ants. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.