Cedar Hill Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 15, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Nov 5, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF700Jun 5, 2022

  Based on observations, interviews, and record reviews the facility failed to assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1of 10 residents (Resident #1) review for bed rails in that: The facility failed to assess Resident #1 for risk of entrapment from bed rails and contact Resident #1's representative to obtain informed consent. Resident #1 lodged his left arm on 05/24/22 into the 1/4 sized bed rail, causing him to sustain a fracture to his left elbow. On 06/03/22 at 3:30 pm an an Immediate Jeopardy was identified. […]

• No harm, potential for more than minimal, widespreadF812Jun 26, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF885Dec 19, 2022

  Based on interview and record review, the facility failed to notify residents and/or the residents' Responsible Party (RP) or families by 5:00 PM the following day, when one (the DM) of one staff member tested positive for COVID-19. The facility failed to inform residents and/or the residents' RP's or families of a confirmed infection of COVID-19 in the facility after the DM tested positive on 12/05/22. This failure placed residents, families, and RP's at risk of not being kept informed of the COVID-19 status in the facility. […]