Cedar Hills Center for Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 27, 2023

  Based on record review and interviews with Guardian, staff, Nurse Practitioner and Physician, the facility failed to report a problem with the door latching between the second-floor unit and the ramp leading down to the first-floor unit. Resident #1 who was severely cognitively impaired exited through the second-floor door on her own, lost control of the wheelchair and rolled down a 150-foot ramp to the first floor. Resident #1 collided with an interior wall on the first floor of the facility. She sustained bilateral femur fractures, a pelvic fracture, and a laceration to her head. The hospital determined she would not survive surgery to repair her fractures and she was admitted to a hospice house for palliative care measures. […]

• Immediate jeopardy, isolatedF925Sep 21, 2022

  Based on record review, observations, and staff, Physician and Wound Care Nurse Practitioner interviews the facility failed to implement fly reduction measures to protect vulnerable residents with wounds from development of maggots and failed to determine a possible point of entry for flies after the infestation to protect all residents at risk, which resulted in 1 of 3 residents (Resident #1) reviewed for wound care from developing maggots in her right foot wound. Resident #1's Family Member was upset and concerned she had not received adequate wound and comfort care to prevent maggots in her wound. Immediate Jeopardy began on 9/12/2022, when Resident #1's right dorsal foot wound was discovered to be infested with maggots. […]

• Actual harm, isolatedF689Nov 8, 2024

  Based 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) Findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia and osteoarthritis. A review of Resident #7's record documented she had the diagnoses added on 9/23/21 of adult failure to thrive, severe protein-calorie malnutrition, cognitive communication deficit, repeated falls, and dysphagia. […]

• No harm, potential for more than minimal, widespreadF812Feb 13, 2026

  Based 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. Findings included: During the initial tour of the kitchen on 2/9/26 at 9:58 a.m., three observations of the operation of the dishwashing machine by Dietary Staff #1 were conducted. The water temperatures ranged from 90 degrees Fahrenheit to 100 degrees Fahrenheit. Dietary Staff #1 continued to send dishware through the dish machine. The Dietary Manager (DM) was not in the dishwashing area of the kitchen during this observation. […]

• No harm, potential for more than minimal, widespreadF814Feb 13, 2026

  Based 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. […]