Cedar Hill Nursing And Rehab Center

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. Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program that must be based on nationally accepted standards. The program must include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; measures to prevent the growth of opportunistic waterborne pathogens (control measures), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Standing water was observed in the drain located in the cook area in front of the steamer. A small drain on the floor in front of walk-in refrigerator was observed to be uncovered and filled with a biofilm slime-like substance around the lip of the drain. Gnats were observed moving around the lip of the uncovered drain. (Photographic evidence obtained) During a follow-up visit to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Another observation was made on 8/8/24 at 10:25 AM of the walk-in freezer located inside the walk-in refrigerator. The door was not closed completely and would not close completely. (Photographic evidence obtained) During a follow-up visit to the kitchen on 8/8/24 at 10:45 AM, another observation was made of the walk-in freezer door not closing completely after several attempts to push the door closed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, facility pest control management documentation, and a review of the facility's policy and procedure, the facility failed to ensure that its pest control service was effective. Cockroaches were observed in four (Rooms 120, 118, 121, and 117) of 66 resident rooms (all on the South Unit), at one (South Unit) of two nurses' stations, and in the kitchen. An ineffective pest control program can result in the transmission of disease/infection. The findings include: From 8/6/24 through 8/9/24, tours of the facility were conducted at various times. Live cockroaches were observed in room [ROOM NUMBER] on 8/6/24 at 10:47 AM. (Photographic evidence obtained). Live cockroaches were observed in room [ROOM NUMBER] on 8/6/24 at 11:03 AM. (Photographic evidence obtained) Live cockroaches were observed in room [ROOM NUMBER] on 8/6/24 at 11:34 AM. (Photographic evidence obtained) Live cockroaches were observed in room [ROOM NUMBER] on 8/7/24 at 9:14 AM. (Photographic evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure that four (Residents #169, #93, #81 and #102) residents from a total survey sample of 32 residents, were provided a clean, comfortable, and homelike environment. Each resident was missing a pillowcase. The findings include: On 8/6/24 at 10:57 AM, an observation was made of Resident #169 resting in bed with his eyes closed. His head was resting on a pillow without a pillowcase. On 8/6/24 at 11:13 AM, an observation was made of Resident #93's bed linens. He was missing a pillowcase. The resident was not present to interview. On 8/6/24 at 11:51 AM, an observation was made of Resident #81's bed linen, which was missing a pillowcase. The resident was interviewed and explained that he had not had a pillowcase in a while but could not remember exactly how many days he went without a pillowcase. He further explained that he previously asked facility staff for a pillowcase and was not provided one. He said it bothered him that he was sleeping on a bare pillow. On 8/6/24 at 1:58 PM, an observation of the linen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policy and procedure review, the facility failed to maintain the physical environment in a sanitary and comfortable manner based on the following: holes in walls, missing base cove molding, and broken and missing closet door panels in four (Rooms 120, 118, 121, and 117) of 66 resident rooms, all of which were located on the South Unit of the facility. These concerns could negatively impact residents' enjoyment of their environment as well as their safety. The findings include: From 8/6/24 through 8/9/24, tours of the facility were conducted at various times. room [ROOM NUMBER] was observed on 8/6/24 at 10:47 AM with wall damage behind the toilet in the bathroom and missing pieces of the closet door panels. (Photographic evidence obtained) room [ROOM NUMBER] was observed on 8/6/24 at 11:03 AM with wall damage and base cove molding damage under the A-bed, a gap in the base cove molding under the air conditioner, and wall damage the length of the air conditioning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a staff interview and a review of facility records, the facility failed to timely report an incident of neglect within 24 hours of the time Administration became aware of the incident. The incident involved the facility staff's failure to properly supervise a resident at risk for elopement. The resident left the facility undetected at 1:58 p.m. on 10/11/23 and was not identified as missing until dinner trays were passed approximately 3.5 hours later. Administration was made aware of the missing resident on 10/11/23 at 5:37 p.m., however, the incident was not reported as required until 10/12/23 at 7:50 p.m. The findings include: A review of facility camera footage for 10/11/23 revealed that Resident #1 walked out of the facility on 10/11/23 at 1:58 p.m. On 10/11/23 at 5:37 p.m., facility staff notified the Administrator and Director of Nursing (DON) that Resident #1 was unaccounted for and a Code Green (facilities internal code that is announced over the paging system to announce a resident is missing)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy and procedure review, the facility failed to provide treatment and care in accordance with professional standards of practice, by failing to contact the physician for a blood glucose reading of Hi for one (Resident #55) of seven residents observed during medication administration, from a total of 34 residents in the sample. The findings include: On 7/19/22 at 11:29 AM, Licensed Practical Nurse (LPN) A was observed performing point-of-care blood glucose testing for Resident #55. After obtaining a blood sample, the blood glucose monitor (BGM) read HI. LPN A prepared the resident's Novolog (insulin) flexpen to administer 12 units subqutaneously. When asked if there was a facility protocol requiring the nurse to notify the physician for blood glucose results that read HI, LPN A stated no, the nursing staff just cover with the insulin. She stated she would notify the resident's physician of the HI reading. Further review of the medical record revealed an active 10/6/2020 physician's order for Novolog Flexpen (insulin),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy and procedure review, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Resident #55) of seven residents observed during medication administration, from a total of 34 residents in the sample. The findings include: On 7/19/22 at 11:29 AM, Licensed Practical Nurse (LPN) A was observed performing point-of-care blood glucose testing for Resident #55. A review of Resident #55's July 2022 Medication Administration Record (MAR), revealed injection sites were not documented. On 7/19/22 at 12:17 PM, LPN A was observed documenting the administration of Resident #55's insulin. A review of the July 2022 MAR revealed no injection site was documented. On 7/20/22 at 12:45 AM, an interview was conducted with LPN/Unit Manager B. She stated the only injectable medication nursing documented the injection site for was Levemir (insulin). They did not document an injection site for Novolog (insulin) or other injectable medications. She stated the surveyor should ask the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.