Cedar Hills Center for Nursing and Rehabilitation

Inspectors wroteBased on observations, record review, staff, and Corporate Nurse Consultant interviews, the facility failed to store medication in its original package with labeling and dispensing instructions (300 hall Medication Cart), failed to remove expired medication (100 hall Medication Cart), and failed to secure two unlocked treatment carts. These failures occurred in 2 of 2 medication carts and 2 of 2 treatment carts (100 and 300 hall) reviewed for medication storage. Findings Included:1). An observation of the 300 hall medication cart was completed on 06/24/2026 at 1:27 PM accompanied by Nurse #2. During this observation five pills were observed loose and not in their original package. The five loose pills were observed in the over-the-counter medication drawer of the medication cart. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to protect resident #8's private healthcare information (PHI) by leaving confidential medical information unattended, visible, and accessible to others on a laptop screen for 1 of 2 treatment carts observed (300-hall treatment cart).

Inspectors wroteBased on record review, staff interviews, and between review and staff the facility failed to ensure 2 of 2 narcotic reconciliation records reviewed were signed and dated when controlled substances were administered (100 and 300 hall).

Inspectors wroteBased on observations and staff interviews, the facility failed to store stock medications securely in the original covered and labeled bottles to prevent errors and possible contamination in 1 of 2 medication carts reviewed for medication storage (300 hall medication cart #1).

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to respect a resident's right to dignity when Resident #16 requested assistance to the bathroom and then incontinence care. Assistance was not provided to Resident #16 until after all the meal trays were passed out on the hall and other residents were assisted with eating. This affected 1 of 4 residents reviewed for dignity (Resident #16).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to protect a resident's right to be free from neglect when Resident #6's call light was disconnected by a staff member. This caused the resident to be unable to access assistance, and Resident #6 was found on the next shift to be soiled with urine and feces. This failure affected 1 of 2 residents who were reviewed for call system concerns (Resident #6).

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide assistance to the bathroom and incontinence care to a resident upon request for 1 of 5 reviewed for the provision of activity of daily living care (Resident #16).

Inspectors wroteBased on record review and staff, family, and resident interviews, the facility failed to provide wound treatments as ordered by a physician for 2 of 5 residents reviewed for the provision of care according to professional standards and the care plan (Residents #5 and #16).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 33 opportunities, resulting in a medication error rate of 6.06% for 1 of 2 residents observed for medication administration (Resident #12).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure the low temperature dishwasher maintained the wash temperature of 120 degrees Fahrenheit (F). These practices had the potential to affect food served to all residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the side doors to trash dumpsters remained closed, failed to contain waste in dumpsters with lids or coverings and failed to maintain a clean garbage area free from litter for 2 of 2 trash dumpsters and 1 of 1 construction container. These practices had the potential to attract pests and rodents. Upon arrival into the parking area of the facility an observation of the dumpster area on 2/9/26 at 9:15 a.m., revealed a long/large open to air construction-type container overflowing with bags of trash with some of the bags on the ground next to one side of building of the facility. There was no covering/tarp over the container or trash bags. On 2/11/26 at 12:07 p.m., accompanied by the Regional Food Service Consultant, an observation of the facility's dumpster area was completed. [...]

Inspectors wroteBased on facility policy review, record review and staff interviews, the facility failed to implement an antibiotic stewardship program to monitor antibiotic usage in the facility. This practice had the potential to affect 87 of 87 residents in the facility.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a baseline care plan within 48 hours of admission for 9 of 30 residents reviewed for baseline care plan (Residents #30, #105, #106, #110, #6, #109, #82, #99, and #72).

Inspectors wroteBased on observations and staff interviews, the facility failed to remove loose and unsecured pills of various shapes, sizes and colors on 2 of 4 medication carts observed (Hall 300 Medication Cart #1 and Medication Cart #2).

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain vaccination consents or declination decisions in the residents' medical record and failed to maintain a record of education of the benefits and potential side effects for the influenza and pneumococcal immunizations for 5 of 5 residents reviewed for immunizations (Resident #21, Resident #20, Resident #9, Resident #72 and Resident #33).

Inspectors wroteBased on record review, resident interview and staff interviews the facility failed to treat a resident in a dignified and respectful manner when Nurse Aide #7 and Nurse Aide #8 were delayed in responding to a resident's call for assistance and told the resident to stop using her call light causing the resident to be upset and mad. The deficient practice affected 1 of 3 residents reviewed for dignity (Resident #82).

Inspectors wroteBased on record review and staff interviews, the facility failed to inform and provide written information to a resident regarding the residents' right to accept or refuse medical/surgical treatment and to formulate an advanced directive for 1 of 33 sampled residents reviewed for advanced directives (Residents #105).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 (liability notice that informs Medicare Part A beneficiaries of potential Medicare non-coverage before providing custodial care or items that are usually paid for by Medicare) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification review (Resident #116 and Resident #117).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan in the areas of activities of daily living and activities (Resident #13), and discharge goal (Resident #4) for 2 of 30 residents whose care plans were reviewed (Resident #13 and Resident #4).

Inspectors wroteBased on observation, record review, and interview of the staff, residents, and a family member, the facility failed to provide dependent residents nail care (Residents #8 and #10) and facial hair care (Resident #10). The deficient practice affected 2 of 10 residents reviewed for activities of daily living (Residents #8 and #10).

Inspectors wroteBased on record review, observation, and interview of staff, the physician assistant, and the wound nurse practitioner, the facility failed to change the pressure ulcer dressing as ordered (Resident #30). The deficient practice affected 1 of 5 residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, physician assistant, and staff interviews the facility failed to obtain ordered urine analysis and culture sensitivity specimen for 1 of 2 residents. (Resident #30) The facility failed to empty the urinary catheter bag as ordered to maintain free urine flow through an indwelling catheter and failed to keep stool away from urinary catheter and the meatus to prevent urinary tract infections for 1 of 2 resident reviewed for urinary catheter care. (Resident #30)1a. Resident #30 was admitted to the facility on [DATE] with diagnosis which included spina bifida with hydrocephalus, paraplegia, neuromuscular dysfunction of bladder, and urinary tract infection. The care plan initiated on 08/14/25 revealed Resident #30 had a urinary catheter related to neurogenic bladder. The goal was Resident #30 would show no signs or symptoms of urinary tract infection. [...]

Inspectors wroteBased on record review, and staff and Physician Assistant interviews, the facility failed to obtain an ordered clostridium difficile test result for a Resident experiencing abdominal tenderness and loose stools (clostridium difficile is a bacterium which can cause diarrhea, abdominal pain and bowel inflammation). The deficient practice occurred on three separate occasions for 1 of 3 residents reviewed for laboratory services (Resident #98).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to implement infection control policies and procedures for enhanced barrier precautions when Nurse Aide (NA) #1 failed to don a gown when starting to provide incontinence care to Resident #105 who had a sacral wound and required surveyor intervention for 1 of 7 staff members observed for infection control practices (NA #1).

Inspectors wroteBased on observations and staff and resident interviews, the facility failed to place survey results in a location readily accessible to residents and visitors and failed to post notice of the availability of the survey results for 1 of 4 days of the survey (2/11/26).

Inspectors wroteBased on observation, record review, and interviews of staff, the facility failed to provide care in a safe manner when a resident rolled off a bed raised to waist height onto the floor. Resident #7 sustained a laceration to the left side of her head which required 5 staples. This deficient practice affected 1 of 4 residents reviewed for accidents. (Resident #7)

Inspectors wroteBased on record review, and staff and resident interviews the facility failed to provide resolution of Resident Council Meeting grievances for 5 of 6 monthly Resident Council Meetings. The Resident Council had repeated concerns regarding coffee not being served before breakfast and clothes not coming back from laundry (5/28/24, 06/25/24, 07/30/24, 08/27/24, and 09/24/24). On 05/28/24 the Resident Council Meeting Minutes noted a dietary concern that coffee was not being served or made before breakfast. The Resident Council Follow-Up form attached to the 05/28/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the Resident Council. On 06/25/24 the Resident Council Meeting Minutes noted a dietary concern that coffee was not being served or made before breakfast. [...]

Inspectors wroteBased on record review, staff interview, Corporate Nurse Consultant and Physician interview the facility failed to follow physician orders to obtain a monthly weight (lbs.) for 1 of 3 residents (Resident #50) reviewed for nutrition.

Inspectors wroteBased on observations, record reviews, resident interview, and staff interviews, the facility failed to provide privacy for a catheter bag and activities of daily living (ADL) care for 2 of 2 residents (Resident #14 and Resident #55) reviewed for personal privacy.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to permit Resident #336 to remain in the facility and initiated the resident's discharge when she returned later than expected from a leave of absence. The resident returned to the facility on 2/12/24 and was informed by staff she was not allowed to remain in the facility due to her being gone from the facility over 24 hours. Additionally, the facility failed to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 of 3 residents reviewed for discharge. (Resident 336).

Inspectors wroteBased on record reviews, staff interviews, and physician interview, the facility failed to provide a safe and orderly discharge for 1 of 3 residents (Resident # 336) reviewed for discharge. On 2/11/24 at 12:30 pm Resident #336 signed out of the facility on leave of absence with an expected return time of 9:30 pm. Due to transportation issues, Resident #336 was not able to return to the facility until 2/12/24 and was informed that she had been discharged and therefore could not remain in the facility. Resident #336 was not provided with discharge instructions or prescriptions, and the discharge location was not verified. This resulted in Resident #336 going to the hospital to get her medications refilled. Resident #336 remained in the hospital under observation until she was readmitted to the facility on [DATE].

Inspectors wroteBased on record review, staff interview and physician interview, the facility failed to comprehensively assess a resident in the area of weights for 1 of 3 residents (Resident #50) reviewed for nutrition.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to provide restorative range of motion and the application of the splinting devices as recommended by the occupational therapist for 1 of 2 sampled resident (Resident #48) reviewed for limited range of motion.

Inspectors wroteBased on record review, resident, staff, and physician interviews, the facility failed to ensure a resident receiving dialysis services had a physician's order for dialysis services, a care plan and failed to monitor after dialysis treatments. This was for 1 of 1 resident reviewed for dialysis (Resident #64).

Inspectors wroteBased on record review, North Carolina (NC) Nurse Aide (NA) Registry Representative and staff interviews, the facility administration failed to have effective systems in place to identify when a nurse aide had an expired registry listing with the NC Nurse Aide Registry for 1 of 5 employees reviewed for sufficient nurse staffing (NA #4).

Inspectors wroteBased on observations, resident, and staff interviews, the facility failed to provide a privacy curtain for 2 of 14 rooms on the 200-hall reviewed for privacy (room [ROOM NUMBER] and room [ROOM NUMBER]).

Inspectors wroteBased on observations and staff interviews, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, and the protection and advocacy network. This observation occurred for 4 of the 4 days during the onsite recertification survey.

Inspectors wroteBased on record review and staff, Pharmacist, Nurse Practitioner, and Resident interviews the facility failed to administer antiseizure medication and pain medication for 2 of 3 residents (Resident #8 and Resident #9) reviewed for providing pharmaceutical services to meet residents' needs. administration. Resident #8 did not receive her antiseizure medication on 7/15/2024 and 7/16/2024, and Resident #9 was admitted with a left total knee replacement and did not receive pain medication when admitted to the facility.

Inspectors wroteBased on record review, observations, Nurse Practitioner, and staff interviews the facility failed to report the results of a urinalysis received on 8/8/2024 to the Nurse Practitioner until 8/12/2024, failed to report pain and distention of the lower abdomen to the Nurse Practitioner on 8/5/2024, and failed to report being unable to flush a urinary catheter for 1 of 1 Resident (Resident #1) reviewed for urinary catheter care.

Inspectors wroteBased on record review, observations, and staff interviews the facility failed to report an allegation of abuse to Adult Protective Services for 1 of 3 residents (Resident #6) who alleged staff to resident abuse which occurred on 7/25/2024 and was reported to the Administrator on 7/26/2024 but was not reported to Adult Protective Services until 8/1/2024.

Inspectors wroteBased on record review and resident, Responsible Party, and Nurse Practitioner interviews the facility failed to have a Urinalysis with Culture sample collected on 8/5/2024 tested at the laboratory that same day. The Urinalysis with Culture was not completed and reported to the facility until 8/8/24. In addition, the facility failed to follow through on 8/8/24 when the laboratory suggested a new urine sample when the results for the 8/5/24 indicated the sample was contaminated. The deficient practice occurred for 1 of 1 resident (Resident #1) reviewed for suprapubic catheter care.

Inspectors wroteBased on record review, observations and staff, Pharmacy Consultant and Nurse Practitioner interviews the facility failed to administer pain medication as ordered for 1 of 3 residents (Resident #9) reviewed for pain management.

Inspectors wroteBased on record review and staff interviews the facility failed to have pain medication available as ordered by the Nurse Practitioner on admission to the facility and provide nursing staff access to the electronic emergency backup medication storage for 1 of 3 residents reviewed for pain management (Resident #9).

Inspectors wroteBased on observation, record review, resident interviews, and staff interviews, the facility failed to place residents' call lights (Resident #12, #19, #15 and #40) within reach to allow for the residents to request staff assistance. This was for 4 of 4 residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, record review, resident interviews, and staff interviews, the facility failed to provide nail care for dependent residents (Resident #15, #19, and #40) and failed to wash a dependent residents (Resident #64) hair. This was for 4 of 12 residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, resident interview, family interview, staff interviews and record review, the facility failed to provide a lunchtime meal to a dialysis resident on 11/02/23, 11/04/23, 11/07/23, 11/09/23, 11/11/23, 11/14/23 and 11/16/23 for 1 of 1residents reviewed for dialysis (Resident #185).

Inspectors wroteBased on record review and staff interviews the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day, for 16 of 30 days (10/13,10/18,10/19,10/20, 10/23. 10/24, 10/27, 10/28, 10/29, 11/01, 11/02, 11/06, 11/07, 11/10, 11/11, and 11/12)) reviewed for staffing.

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to remove expired medications and failed to remove loose pills from 1 of 2 medication carts reviewed and failed to remove expired medications from 1 of 2 medication storage rooms reviewed (300B medication cart and 200 hall medication storage room).

Inspectors wroteBased on test tray observation, record reviews, and interviews with residents and staff the facility failed to serve food that was palatable and at temperatures acceptable to 5 of 8 residents reviewed for food palatability (Resident #1, Resident #3, Resident #22, Resident #26, and Resident #38). This practice had the potential to affect other residents.

Inspectors wroteBased on observations, record review, resident and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor intervention the committee put in place following a complaint survey conducted on 12/17/20. This was evident for 1 deficiency that was cited in the area Comprehensive Resident Centered Care Plan (Develop/Implement Comprehensive Care Plan) and on the current recertification and complaint survey conducted on 11/17/23. The facility's Quality Assessment and Assurance (QAA) Committee also failed to maintain implemented procedures and monitor intervention the committee put in place following a complaint survey conducted on 1/28/21. This was evident for 1 deficiency that was cited in the area of Quality of Care and on the current recertification and complaint survey on 11/17/23. [...]

Inspectors wrote3. Resident #54 was initially admitted to the facility on [DATE] with diagnoses that included diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54 received one injection of insulin during the last seven days looked at for the 9/23/23 assessment. Review of the Medications Administration Record (MAR) for September 2023 showed Resident #54 received dulaglutide (once a week injection used to improve blood sugar) an injection of 0.75 milligram (mg) subcutaneously (under the skin, between the skin and muscle) on 9/21/23. Review of the MAR for September 2023 showed Resident #54 received insulin lispro (fast acting injectable insulin) on the following days: 9/16/23, 9/17/23, 9/18/23, 9/20/23, 9/21/23, and 9/22/23. An interview was conducted on 11/16/23 at 12:45 P.M. with the MDS Nurse #2 . [...]

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to develop an individualized and comprehensive care plan or interventions after falls (Resident #15), for a resident at risk for pressure ulcers and urinary incontinence (Resident #78) and failed to care plan a wanderguard (Resident #14). This was for 3 of 20 residents whose care plans were reviewed.

Inspectors wroteBased on observations, record review, resident, and staff interview the facility failed to obtain a physician's order and perform dressing changes for a skin tear to a Resident's left upper arm for 1 of 1 resident reviewed for skin condition (Resident #78).

Inspectors wroteBased on observation, staff interviews, and record review the facility failed to identify the root cause for six falls and implement effective interventions to prevent six falls (Resident #15). This was for 1 of 7 residents reviewed for accidents.

Inspectors wroteBased on observations, record reviews, interviews with staff and interview with the Pharmacist Consultant, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.54% for 2 of 3 residents (Resident #45 and Resident #11) observed during the medication administration observation.

Inspectors wroteBased on observations and interviews with residents and staff, the facility failed to maintain floors free from dried spills and debris for two rooms (room [ROOM NUMBER] and 318) This deficient practice affected 1 of 3 resident halls (300 Hall).