Cedar Hill Health Care Center

In the surveyor’s words

From the most serious findings on record at Cedar Hill Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 15, 2025

  Based on the interview and record review, the facility failed to monitor and respond appropriately to a hyperglycemic event for 1 of 12 residents (Resident #38), who had a known diagnosis of diabetes mellitus and chronic kidney disease. Specifically, the facility failed to monitor blood glucose levels and vital signs following a critically elevated glucose reading of 567 mg/dL and failed to reassess the resident's condition after insulin administration. These failures were inconsistent with professional standards of practice and the facility's own diabetes care policy and resulted in the resident being found deceased approximately ten hours after the event, without documented follow-up monitoring. […]

• No harm, potential for more than minimal, widespreadF801Dec 15, 2025

  Based on interview and record review the facility failed to ensure that the dietary manager possessed the required qualifications for the position. This deficient practice has the potential to affect all residents. Findings include: Per interview with the Dietary Manager on 9/24/2025 at 3:10 PM she had been enrolled in a Dietary Manager class but had to put it on hold due to the Dietician being away. The Dietary Manager confirmed that the Registered Dietician is not employed on a full-time basis and that she does not have the required qualifications to meet the regulatory requirements. […]

• No harm, potential for more than minimal, widespreadF919Jun 20, 2024

  Based on observation, interview, and record review the facility failed to ensure that each resident had access to an effective call system at their bedside for 2 of 21 residents sampled (Resident #1 and #7). This deficient practice has the potential to affect all residents who reside in the facility. Findings include: 1. During unit observations and resident interview on 6/17/24 at 3:03 PM, Resident #1 was observed sitting in a recliner in their room trying to get assistance to go to the bathroom. Resident #1 was asked by the Surveyor if they could ring their call bell to alert staff that s/he needed assistance. The Resident stated that s/he had been ringing and ringing and nobody was coming. The Surveyor pushed the call light button, and nothing happened. […]

• No harm, potential for more than minimal, patternF726Jun 20, 2024

  Based on interview and record review the facility failed to ensure that 1 of 4 sampled licensed nursing assistants (LNAs) and 2 of 2 sampled Licensed Practical Nurses (LPNs) were assessed for competency in the skills required to care for the resident needs based on resident care plans. Findings include: 1. Review of 1 LNA education and competency file revealed an orientation checklist that was signed off by another LNA; however, there was no evidence that the LNA was assessed for competency by a licensed nurse. 2. Review of the education and competency file for 1 LPN who was hired on 5/29/2024 revealed no evidence that they were assessed for competency in the skills needed to care for the residents. 3. […]

• No harm, potential for more than minimal, patternF583Apr 20, 2022

  Based on observation, staff interview, and record review the facility failed to ensure that resident personal and medical information was maintained in a secure and confidential manner, so that others would not have access to it for 1 of 19 sampled residents and 1 of 2 medication carts with identifying information for all residents. Findings include: 1. Per observation on 4/20/2022 at 2:11 PM a sign was posted on the outside of the door, toward the hallway of room [ROOM NUMBER] that stated: Infection Prevention and Control Policy for Suspected or Confirmed Coronavirus (COVID 19); Room log: Residents with suspected or confirmed Coronavirus (COVID 19); Residents name: [The resident's name was written in]; Employee or Visitor Name: Date: Time In: Time Out: An employee had signed in on… […]