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Complaint Investigation

Cedar Hill Healthcare Center

Inspection Date: August 15, 2025
Total Violations 1
Facility ID 675032
Location Cedar Hill, TX
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Inspection Findings

F-Tag F0689

Quality of Life and Care Deficiencies
Harm Level: Immediate Jeopardy

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

elopement drills on 07/31/25, The admin stated they did monthly elopement drills. The Admin stated the facility completed upgrades to the alarm system that included blinking strobe lights and horn that could be heard throughout the facility. In an Interview on 08/14/25 between 1:15pm to 2:30 pm revealed staff were knowledgeable about the policy and procedures for elopement and drills. LVN E, RN F, CNA G, CNA H, CNA I, CNA J, CNA K, RN L, CNA M, CNA N, LVN O, RN Q and CNA P stated they had been doing random drills for elopement. Staff stated when the alarm went off look outside, do head count, and let the charge nurse and admin know the alarm went off. The staff stated search the inside of the building then extend the search to the outside. The staff stated call code white for elopement over the intercom. RN L, RN F, RN Q and LVN O stated when the resident was found a head-to-toe assessment was to be completed and an incident report. During an observation on 08/14/25 at 4:15 pm revealed the Admin set the front door alarm off. The Admin lightly pushed the door and she stated that was the sound the door would make

before the upgrade. The surveyor observed the sound was able to be heard in the front of the building but, was too low to be heard throughout the building. The surveyor heard the horn and flashing lights throughout

the facility. Observed staff running to the front of the building. Observed exit doors throughout the building and no concerns noted at this time. In an interview on 08/15/25 at 9:35 am the PA stated the facility notified her on Saturday 07/19/25 that Resident#1 had eloped from the facility. The PA stated she gave the order for Resident#1 to be put on the secure unit. The PA stated Resident#1 was combative with staff and exit seeking. The PA stated at this time Resident#1 was appropriate for the secure unit. Record review of Tulip (A web- based system implemented for managing the licensure of long-term care facilities and agencies) reflected a self- report was submitted on 07/18/25. Record review of IC approved quote dated 08/04/25 reflected strobe white wall, amber lens and system sensor wall mini horn, white for installment for upgrades to alarm system.

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📋 Inspection Summary

Cedar Hill Healthcare Center in Cedar Hill, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Cedar Hill, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Cedar Hill Healthcare Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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