Cedar Hollow Rehabilitation Center

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

12/30/2025 at 4:33 PM, the DON stated it was important for staff to know the appropriate care to provide residents. She stated staff must follow the care plan interventions to prevent injury to the resident and to promote quality of life. She stated staff received in-service training on the importance of following residents' plans of care. She stated staff received in-service training on how to transfer residents and were required to demonstrate their ability to complete safe transfers.Interviews on 12/30/2025, between 1:24 PM and 4:29 PM, were conducted with multiple staff members which included the Executive Director, Director of Nurses, Assistant Director of Nurses, RN A, CNA B, LVN C, Director of Rehabilitation, CNA D, CMA E, CNA F, LVN G, LVN H, CNA/Staff Coordinator, LVN I, RN J, CNA K, CMA L, CNA M, and CNA N. Interviews revealed staff received in-service training with the therapy department and were required to demonstrate gait belt and Hoyer lift transfers. Interviews revealed staff members knew how to locate a resident's transfer status in

the plan of care and understood it was important to follow appropriate interventions to prevent injury to the resident and staff. The facility initiated the following preventions prior to the state surveyor entry on 12/30/2025:On 12/01/2025 the interdisciplinary team completed a review of all residents' transfer status.Record review of the facility provided documentation, dated 12/01/2025, reflected all nursing staff received in-service training on resident neglect, where to locate residents' transfer status, and how to properly transfer with a gait belt and Hoyer lift.Record review of the facility provided documentation, dated 12/01/2025, reflected one on one in-servicing provided to CNA B with return demonstration related to mechanical lift transfers, one person and two person transfers. The employee corrective action form, dated 12/01/2025, reflected CNA B received disciplinary action for failure to use proper transfer technique with one resident. Record review of the facility provided monitoring logs, dated 12/05/2025 to 12/30/2025, reflected 2 nursing staff were observed per week for proper use of resident transfers. No concerns were noted. Record review of the facility provided monitoring log, dated 12/01/2025 to 12/30/2025, reflected clinical records were monitored for accurate transfer status five times a week. No concerns were noted.Record review of the facility provided monitoring log, dated 12/01/2025 to 12/30/2025, reflected at least 15 staff members were interviewed each week regarding resident transfer status. No concerns were noted.Record review of the facility's policy Care Planning - Interdisciplinary Team, reviewed December 2024, reflected Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Hollow Rehabilitation Center

5011 North US Hwy 75 Sherman, TX 75090

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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

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

in the plan of care and understood it was important to follow appropriate interventions to prevent injury to

the resident and staff. The facility initiated the following preventions prior to the state surveyor entry on 12/30/2025:On 12/01/2025 the interdisciplinary team completed a review of all residents' transfer status.Record review of the facility provided documentation, dated 12/01/2025, reflected all nursing staff received in-service training on resident neglect, where to locate residents' transfer status, and how to properly transfer with a gait belt and Hoyer lift.Record review of the facility provided documentation, dated 12/01/2025, reflected one on one in-servicing provided to CNA B with return demonstration related to mechanical lift transfers, one person and two person transfers. The employee corrective action form, dated 12/01/2025, reflected CNA B received disciplinary action for failure to use proper transfer technique with one resident. Record review of the facility provided monitoring logs, dated 12/05/2025 to 12/30/2025, reflected 2 nursing staff were observed per week for proper use of resident transfers. No concerns were noted. Record review of the facility provided monitoring log, dated 12/01/2025 to 12/30/2025, reflected clinical records were monitored for accurate transfer status five times a week. No concerns were noted.Record review of the facility provided monitoring log, dated 12/01/2025 to 12/30/2025, reflected at least 15 staff members were interviewed each week regarding resident transfer status. No concerns were noted.Record review of the facility's policy Safe Lifting and Movement of Residents, revised December 2024, reflected In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan.

1. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when

necessary. 11. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Hollow Rehabilitation Center

5011 North US Hwy 75 Sherman, TX 75090

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to ensure that a resident, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four (Resident #1) residents reviewed for respiratory care.The facility failed to ensure Resident #1's nebulizer mask (device used to deliver medication in a mist form through the nose and mouth) was properly stored when not in use on 12/30/2025.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 12/30/2025, reflected a [AGE] year-old female who initially admitted to the facility on [DATE REDACTED] and readmitted

on [DATE REDACTED]. Resident #1 had diagnoses which included acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood) and shortness of breath. Record review of Resident #1's Quarterly MDS Assessment, dated 12/19/2025, reflected the resident was cognitively intact with a BIMS score of 13.

Section I (Active Diagnoses) reflected respiratory failure. Section O (Special Treatments, Procedures, and Programs) reflected Resident #1 received oxygen therapy. Record review of Resident #1's Comprehensive Care Plan, dated 12/30/2025, reflected Resident #1 had oxygen therapy as needed related to respiratory failure. One intervention was to give medication as ordered and monitor for signs of respiratory distress.Record review of Resident #1's Physician Order, dated 12/05/2025, reflected Budesonide Inhalation Suspension 0.5 MG/2ML Budesonide (Inhalation) 1 vial inhale orally two times a day for acute and chronic respiratory failure with hypoxia.During an observation on 12/30/2025 at 10:09 AM, revealed Resident #1 was lying in bed. Resident #1 was receiving oxygen therapy via nasal cannula (device used to deliver oxygen into the nostrils). An empty plastic bag hung from the nightstand drawer handle. Resident #1 gave permission for the drawer to be opened. A nebulizer machine with connected tubing and a face mask was in the drawer with other personal items. The nebulizer mask was not in a bag. Resident #1 stated she did not know if the nebulizer mask was supposed to be in a bag. During an interview on 12/30/25 at 10:29 AM, RN A stated the nebulizer mask should have been stored in a bag when not in use. She stated as the resident's nurse, she was responsible for ensuring it was stored in a bag when the resident was not receiving a breathing treatment. She stated the risk to the resident was respiratory infection.During an

interview on 12/30/25 at 11:28 AM, the DON stated the nebulizer mask should have been stored in a bag when not in use. She stated that any staff member could notice if it was not bagged and notify the nurse.

She stated ultimately the nurse was responsible. She stated it was important to prevent infection. Record

review of the facility's policy Departmental (Respiratory Therapy) - Prevention of Infection, reviewed December 2024, reflected Infection Control Considerations Related to Nebulizer/Continuous Aerosol. Store

the circuit in plastic bag, marked with date and resident's name, between uses.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Hollow Rehabilitation Center

5011 North US Hwy 75 Sherman, TX 75090

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of five (Resident #1) residents reviewed for medication storage.The facility failed to ensure over the counter medication was not on Resident #1's bedside table on 12/30/2025. This failure could place the residents at risk of accidental overdose or misuse of medication.Findings include: Record review of Resident #1's Face Sheet, dated 12/30/2025, reflected a [AGE] year-old female who initially admitted to the facility on [DATE REDACTED] and readmitted

on [DATE REDACTED]. Resident #1 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), age-related osteoporosis (disease that weakens bones), and initial encounter for a left femur (long bone in upper leg) closed fracture (broken bone with intact skin). Record review of Resident #1's Quarterly MDS Assessment, dated 12/19/2025, reflected the resident was cognitively intact with a BIMS score of 13. Section GG indicated Resident #1 was dependent on staff for self-care and mobility needs.

Record review of Resident #1's Comprehensive Care Plan, dated 12/01/2025, did not reflect the resident self-administered her medication.During an observation and interview on 12/30/2025 at 10:09 AM, revealed Resident #1 was lying in bed awake. The bedside table was placed over the right side of her bed. A plastic container on the bedside table held a tube of Voltaren cream (treats arthritis pain), a box of Pepto Bismol chewable tablets (used to treat nausea and heartburn), saline nasal spray (moistens and clears the nasal passage), Icy Hot pain relief cream (used for muscle and joint pain), and Mentholatum ointment (used to relieve minor aches, pain, and congestion). The plastic container also held other personal items. Resident #1 stated the medicine was there in case she needed it. During an interview on 12/30/25 at 10:29 AM, RN

A stated Resident #1 had several family members who came to see her and at times went to the store and brought items the resident requested. She stated medication should not be left in Resident #1's room unless she was assessed and checked off to self-administer it. RN A removed the over-the-counter medications. Resident #1 asked what she was doing with the medication and RN A replied to ensure everyone's safety, the medications could not be left in her room. During an interview on 12/30/2025 at 11:28 AM, the DON stated Resident #1 should not have over the counter medications in her room. She stated the resident had multiple family members and facility staff had conversations with them about bringing items into her room. The DON stated the resident did not self-medicate and it was also important to ensure no one else had access to the medication. During an interview on 12/30/2025 at 3:55 PM, the Executive Director stated Resident #1 should not have medication in her room. She stated it was important for the nurse to know what medication the resident took. She stated someone else might take the medication and potentially have an adverse reaction. She stated she would send a reminder email out to all family members reminding them not to bring medication to the facility. Record review of the facility's policy Storage of Medications, reviewed December 2024, reflected The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. Drugs shall be stored in

an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Event ID:

Facility ID:

If continuation sheet