CEDAR HILL HEALTHCARE CENTER

Nursing Home Inspector

230 S CLARK RD
CEDAR HILL, TX 75104
Dallas County
Phone: 972-291-7877
Provider Number: 675032
Last Inspection: 08/31/2017

About the Nursing Home

Number of Beds: 120
Number of Residents: 77
Beds Available: 43
Percent Occupancy: 64%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Government - Hospital district
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

10

Facility
11

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

10

2017
22

2016
36

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/31/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 9/1/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 9/1/2017
 

9/22/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that all required doctor visits are made personally. Pattern : Minimal 4 10/10/2016
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Widespread : Minimal 5 11/1/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/12/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 10/25/2016
 
Failed To: Make sure that doctors visit residents regularly, as required. Pattern : Minimal 4 10/10/2016
 

9/25/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 10/23/2015
 
Failed To: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Isolated : Minimal 3 10/23/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/23/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 10/23/2015
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Widespread : Minimal 5 10/23/2015
 
Failed To: Make sure that special or therapeutic diets are ordered by the attending doctor. Pattern : Minimal 4 10/23/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 10/23/2015
 
Failed To: Keep all essential equipment working safely. Widespread : Minimal 5 10/23/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

11/20/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Immediate 6 11/21/2016
 
Failed To: Provide timely notification to the resident before transfer or discharge. Pattern : Minimal 4 11/21/2016
 

9/16/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Pattern : Immediate 6 9/16/2016
 

4/3/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Pattern : Actual 5 4/24/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Actual 5 4/24/2015
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Pattern : Actual 5 4/24/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Actual 5 4/24/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 77 84.23 75.11
Registered Nurses 0.81 0.65 0.59
Licensed Practical / Vocational Nurses 0.66 0.88 0.94
Certified Nursing Assistants 2.03 2.14 2.20
Total Staff Hours 3.51 3.68 3.73

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TX State Avg%
of high risk long-stay residents with pressure ulcers 5 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 82 91 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 91 88 92
of long-stay residents experiencing one or more falls with major injury 2 2 3
of long-stay residents who have depressive symptoms 0 3 3
of long-stay residents who lose too much weight 2 4 5
of long-stay residents who received an antianxiety or hypnotic medication 24 20 26
of long-stay residents who received an antipsychotic medication 33 15 17
of long-stay residents who self-report moderate to severe pain 2 2 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 17 22 20
of long-stay residents whose need for help with daily activities has increased 18 19 18
of long-stay residents with a catheter inserted and left in their bladder 1 2 2
of long-stay residents with a urinary tract infection 1 2 3
of low risk long-stay residents who lose control of their bowels or bladder 30 53 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 49 77 77
of short-stay residents who had an outpatient emergency department visit 20 12 13
of short-stay residents who made improvements in function 64 53 59
of short-stay residents who newly received an antipsychotic medication 13 2 2
of short-stay residents who self-report moderate to severe pain 14 10 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 49 72 74
of short-stay residents who were rehospitalized after a nursing home admission 24 25 23
of short-stay residents with pressure ulcers that are new or worsened 1 42 46