Cedar Hollow Rehabilitation Center

jeopardy to resident health or safety

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.

• 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Hollow Rehabilitation Center

5011 North US Hwy 75 Sherman, TX 75090

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Hollow Rehabilitation Center

5011 North US Hwy 75 Sherman, TX 75090

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID: