Cedar Hill Nursing and Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 17, 2023

  Based on staff interviews, resident and facility record reviews, and a review of the facility's policies titled Reporting Abuse to Facility Management (Revised February 2014), Elopements (revised February 2014), and the facility's Elopement Drill Process/Missing Resident Process, the facility failed to ensure residents were free from neglect, by failing to provide supervision and interventions to maintain resident safety, prevent elopement (a resident who is incapable of adequately protecting themself, who leaves the facility unsupervised and undetected), and minimize the risk of injury or death. This resulted in one (Resident #1) of three residents reviewed for elopement risk, departing the facility unescorted and remaining missing from the facility from 1:58 p.m. […]

• Immediate jeopardy, isolatedF689Oct 17, 2023

  Based on staff interviews, resident and facility record reviews, a review of the facility's policy titled Elopements (revised February 2014), and the facility's Elopement Drill Process/Missing Resident Process, the facility failed to ensure residents were provided supervision and interventions to maintain safety, prevent elopement (a resident who is incapable of adequately protecting themself, who leaves the facility unsupervised and undetected), and minimize the risk of injury or death. This resulted in one (Resident #1) of three residents reviewed for elopement risk, departing the facility unescorted and remaining missing from the facility from 1:58 p.m. on [DATE] until approximately 4:00 a.m. […]

• No harm, potential for more than minimal, widespreadF880Aug 9, 2024

  Based on facility record review, staff interview, and facility policy and procedure review, the facility failed to develop and implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water system for its current census of 116 residents. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. […]

• No harm, potential for more than minimal, patternF812Aug 9, 2024

  Based on observations, staff interviews, and facility policy and procedure review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Proper sanitation is important in health care settings to prevent the outbreak of foodborne illness. Nursing home residents are at risk for serious complications from foodborne illness due to their already compromised health status, and standing water, biofilm, and pests such as gnats and roaches are sources of contamination. The findings include: A kitchen tour was conducted on 8/6/24 at 10:24 AM. The facility's oven was opened for observation and two roaches were observed crawling inside. […]

• No harm, potential for more than minimal, patternF908Aug 9, 2024

  Based on observations, staff interviews, and facility policy and procedure review, the facility failed to maintain kitchen equipment in safe operating condition. The kitchen's freezer door would not close properly, leaving the possibility open for potential thawing or partial thawing of frozen food items. This could result in the outbreak of foodborne illness affecting residents who receive food from the facility's kitchen. The findings include: A kitchen tour was conducted on 8/6/24 at 10:24 AM. The walk-in freezer door, located inside the walk-in refrigerator, would not close completely after several attempts to push the door closed to exit back into the walk-in refrigerator. […]