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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?
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 2024-09-24 2024-10-25 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-09-24 2024-10-25 N
Provide properly protected cooking facilities. Fire Safety 2024-09-24 2024-10-25 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-09-24 2024-10-25 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-09-24 2024-10-25 N
Have power receptacles that are properly grounded. Fire Safety 2024-09-24 2024-10-25 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-09-24 2024-10-25 N
Reasonably accommodate the needs and preferences of each resident. Health 2024-09-20 2024-10-21 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 2024-09-20 2024-10-21 N
Keep residents' personal and medical records private and confidential. Health 2024-09-20 2024-10-21 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-09-20 2024-10-21 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2024-09-20 2024-10-21 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-09-20 2024-10-21 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-09-20 2024-10-21 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2024-09-20 2024-10-21 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2024-09-20 2024-10-21 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2024-09-20 2024-10-21 N
Ensure that residents are free from significant medication errors. Health 2024-09-20 2024-10-21 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 2024-09-20 2024-10-21 N
Provide and implement an infection prevention and control program. Health 2024-09-20 2024-10-21 N
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

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