Cedar Hill Health Care Center

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. Resident #1 was pleading for help to get to the bathroom. The Surveyor went to get a Licensed Nursing Assistant (LNA) to assist. The LNA stated that s/he was not aware that Resident #1 was in need of assistance. The LNA also stated that the call lights don't work a lot of the time, and that the residents have been given hand bells…

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 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. Review of the education and competency file for 1 LPN who was hired on 8/23/17 revealed no evidence of annual competency evaluation of the skills needed to care for the residents. Durning interview on 6/19/2024 at 2:04 PM the Director of Nursing and the Human Resource Director confirmed that there was no evidence that the above LNAs and LPNs had been assessed for competency.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and record review the facility failed to report an incident of alleged abuse to the state licensing agency for 1 resident (Resident #30) of 21 sampled residents. Findings include: Per resident interview on 6/19/24 at 11:36 AM Resident #30 stated that a staff member on the overnight shift had made a fist at her/him and stated, You can't even walk. I can knock the shit out of you. Resident #30 stated that s/he had reported this incident to a Licensed Nursing Assistant (LNA) that morning. Per record review of the facility's Abuse, Neglect, and Exploitation policy [last reviewed on 1/27/23], Reporting of all alleged violations are brought to the charge nurse and then the nurse on call. The nurse on call notifies the director of nursing and the administrator. The Director of Nursing, administrator, or designate will notify the state agency ([NAME]), Adult Protective Services [APS] . On 6/19/24 at 12:02 an interview was conducted with the DON [Director of Nursing] and 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 upon interview and record review, the facility failed to revise resident care plans related to fall prevention for 1 resident [Res.#25] of 21 sampled residents. Findings include: Per review of the facility's Falls-Clinical Protocol policy, the staff and physician will identify pertinent interventions to try to prevent subsequent falls. [Nursing Services Policy and Procedure Manual for Long Term Care- revised March 2018] Review of the facility's Nursing Floor Communication Resource reveals under 'Falls' Update the resident's care plan with a new intervention EVERY time a fall occurs with the resident. An interview was conducted with the facility's Director of Nursing [DON] on 6/19/24 at 9:09 AM. The DON stated that the facility's procedure after a resident fall is to update the resident's care plan with new intervention[s] to prevent future falls. The DON confirmed that incident reports and Nursing Notes documented Res.#25 suffering falls on 12/8/23, 12/10/23, 1/8/24, 1/10/24 and 3/24/24. The DON confirmed that Res.#25's care plan contained no new interventions to prevent…

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 staff interview and record review, the facility failed to ensure that records are complete, readily accessible, and systematically organized related to a resident's required pharmacy review for 1 out of 5 sampled residents (Resident # 3). Findings include: Per record review, Resident # 3 was admitted to the facility on [DATE]. There was no evidence in the record that pharmacist conducted a monthly medical record review since admission. During an interview with the Director of Nursing (DON) on 06/18/2024 at approximately 3:30 PM s/he stated that the facility recently changed pharmacy providers. The new pharmacist visited the facility and removed the previous pharmacy recommendations from paper charts and brought them home to review. The DON confirmed at the time of interview that the pharmacy recommendations were not on site or in Resident # 3's medical record. The DON stated that the pharmacist was currently on vacation and was unsure if s/he would be able to obtain the reviews. The DON was able to…

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 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 4/19/22 at 7:20 AM and 9:30 AM. This sign in sheet was located on the door next to a sign that stated STOP: Modified DROPLET PRECAUTIONS. Visitors MUST report to Nursing Station before entering. visitors and staff must: Wear a mask…

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 reviews, the facility failed to ensure the plan of care for 2 of 19 sampled residents in a standard survey sample were revised to reflect necessary care and services. (Residents #9, and #15). Findings include: 1. Observation on 4/18/2022 at 11:50 am, Resident #9 was sitting in the common area in a wheelchair without footrests. A licensed nursing assistant (LNA) asked her/him to pick up her/his feet and began to push the resident to the dining room. The resident did lift her/his feet up while the LNA pushed her/him to the dining room although she/he did put her/his feet down a few times during the transport. Observation on 4/18/22 at 11:52 AM, revealed a pair of wheelchair foot pedals on top of Resident #9's dresser in her/his room. Review of Resident #9's care plan revealed, has limited physical mobility r/t [related to] Parkinson's Disease, dementia and a non-repaired left hip fracture with the following intervention Resident needs assistance with moving [pronoun omitted] scoot w/c [wheelchair] but can also self-propel short distances.…

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 and interview, the facility failed to ensure drugs and biologicals are stored in accordance with accepted professional standards for 1 of 2 medication carts. Findings include: Observation on 4/20/22 10:50 AM - 11:03 AM revealed an unlocked medication cart. The nurse was observed behind a tall wall in the nurses station that separated the nurses station from the medication carts and prohibited a constant visual of the medication cart. Upon the nurses return to the medication cart at 11:03 AM, s/he immediately locked the medication cart.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary environment, specifically in one shared resident bathroom for 2 of 22 resident rooms. Findings include: During unit observations on 4/18/2022 at 11:45 AM and 3:30 PM, in the bathroom located between rooms [ROOM NUMBERS] there was dried splattered feces on the wall next to the toilet. This was observed again the next day, on 4/19/2022 at 2:24 PM. On 4/19/2022 at 2:24 PM the Environmental Manager (EM) was shown the feces on the wall next to the toilet. The EM stated Okay, the housekeeper has not been in here today because the residents were in and out of the bathroom all day. As you can see the trash is full and has not been emptied. When told that the feces had been there the prior day s/he stated I will get [her/him] in here now to clean this.