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Deficiency Records for Cedar Hill Healthcare and Rehabilitation Center
A list of the most recent deficiencies for Cedar Hill Healthcare and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Cedar Hill Healthcare and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-14 | 2024-03-25 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-02-14 | 2024-03-20 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-02-14 | 2024-03-20 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-14 | 2024-03-20 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-01-04 | 2024-03-04 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-01-04 | 2024-03-04 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-01-04 | 2024-03-04 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-13 | 2023-11-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-13 | 2023-11-24 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-13 | 2023-11-24 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-13 | 2023-11-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-13 | 2023-11-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-13 | 2023-11-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-13 | 2023-11-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-13 | 2023-11-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-13 | 2023-11-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-13 | 2023-11-24 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-10-13 | 2023-11-24 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-10-11 | 2023-11-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-11 | 2023-11-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-11 | 2023-11-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-11-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-11 | 2023-11-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-11 | 2023-11-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-11 | 2023-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-29 | 2023-07-28 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-06-29 | 2023-07-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-23 | 2023-06-23 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-28 | 2022-11-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-09-28 | 2022-11-02 | N |
| Meet other general requirements. | Fire Safety | 2022-09-28 | 2022-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-28 | 2022-11-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-28 | 2022-11-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-28 | 2022-11-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-29 | 2022-10-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-29 | 2022-10-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-29 | 2022-10-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-29 | 2022-10-25 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-09-29 | 2022-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-29 | 2022-10-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-10 | 2022-08-26 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-08-10 | 2022-08-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-26 | 2022-05-27 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-13 | 2022-05-10 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-03-23 | 2022-04-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-27 | 2021-12-10 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-10-27 | 2021-12-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-10-27 | 2021-12-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-27 | 2021-12-10 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-27 | 2021-12-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-27 | 2021-12-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-27 | 2021-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-27 | 2021-12-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-27 | 2021-12-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-27 | 2021-12-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-27 | 2021-12-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-27 | 2021-12-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-27 | 2021-12-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-27 | 2021-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-27 | 2021-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-12-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-25 | 2021-11-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-25 | 2021-11-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-25 | 2021-11-26 | N |
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