Health inspection·January 22, 2021

F 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure it met the requirements for testing frequency of asymptomatic residents per the facility infection control assessment and the positivity rate of COVID-19 for the facility's county. This involved seven (Resident #25, #27, #7, #121, #30, #2 and #55) of 32 sampled residents from a facility census of 91. Residents Affected - Few The findings include: An interview was conducted with the facility administrator on 01/21/21 at 11:35 AM. He confirmed that the facility had a staff sample for COVID-19 collected on 01/05/21 at 8:27 AM, with results received on 01/08/21 at 12:44 PM. The administrator provided a copy of the results, which revealed that Employee H, Licensed Practical Nurse (LPN), had a positive result for SARS-CoV-2/COVID-19. An interview was conducted with the Infection Control (IC) Nurse, the Director of Nursing (DON), the Administrator and the Director of Operations on 01/21/21 at 2:27 PM. During the interview, it was confirmed that all staff reported to the front entrance and were screened for exposure to COVID-19 and risk factors, including the staff assigned to the COVID-19 positive unit. The IC Nurse stated the facility tested staff twice a week at the time, however residents were not tested for COVID-19 twice a week. The IC Nurse reported a current county positivity rate of 11.1%. During an interview with the IC Nurse on 01/21/21 at 3:09 PM, she stated she did not need to test residents when Employee H, LPN, tested COVID-19 positive on 01/08/21. An interview was conducted on 01/22/21 at 12:43 PM with the Chief Operating Officer and the IC Nurse, who confirmed that the facility had not reached out to the Department of Health or the Agency for Health Care Administration to report any problems with testing for COVID-19 or for the unavailability of supplies for testing. A review was conducted of the facility's documentation in the Emergency Status System (ESS) from 12/23/20 through 01/22/21. Under Additional Remarks on line 10 (For the previous day (12:00 AM to 11:59 PM), total number of residents that were tested for COVID-19.), the facility documented that no resident testing for COVID-19 occurred from 01/09/21 through 01/22/21. However, on 01/07/21, the facility documented on line 6 (Number of staff who have tested positive for COVID-19:), that two staff members tested positive for COVID-19. A review of the final results from the COVID-19 testing for Employee I, LPN, collected on 12/21/20 at 4:07 PM and released on 12/24/20 at 4:30 PM, revealed that Employee I was COVID-19 positive. Employee H, LPN, was tested on [DATE] at 8:27 AM and results were released on 01/08/21 at 12:44 PM, Page 1 of 4 105721 105721 01/22/2021 Cedar Hill Nursing and Rehab Center 5888 Blanding Blvd Jacksonville, FL 32244

F 0886 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicating that Employee H was positive for COVID 19. Employee J, Dietary Staff, was tested on [DATE] at 7:29 AM and results were released on 01/21/21 at 6:29 AM, indicating that Employee J was positive for COVID-19. These staff members were all working in the facility at the time of their positive test results. A review of the county positivity rate at http://ahca.myflorida.com/docs/PositivityRate2021.pdf, was conducted for the dates of 01/10/21 through 01/16/21. The positivity rate in the county the facility was located in was 11.1% at the time Employees I, H and J tested positive for COVID-19. Testing documentation was reviewed with the Director of Operations on 01/22/21 at 2:27 PM. He did not provide the testing frequency for Residents #25, #27, #7, #121, #30, #2 or #55 under 483.80 (h) at (iv). The criteria for conducting testing of asymptomatic individuals as specified in this paragraph, included the use of the positivity rate of COVID-19 in a given county. A list of residents who were immunized was provided by the Director of Operations. The residents identified above were not documented as having been immunized for COVID-19. An interview was conducted on 01/21/21 at 3:09 PM with the IC Nurse, who stated the facility did not need to implement resident testing based on the definition of outbreak provided in the clinical questions about COVID-19: COVID-19 Risk. (Photocopy obtained) A review of the facility's Infection Prevention and Control Program described the Infection Preventionist's responsibilities, in part, under subparagraph V. Responsibilities: Policies and Procedures are reviewed periodically and revised as needed to conform to current standards of practice to address specific measures. (Copy obtained) A review of the Centers for Medicare and Medicaid Services (CMS) Memorandum,QSO-20-38-NH, dated 8/26/2020 under table two, showed that a positivity rate greater than 10%, indicated testing should occur twice a week. It also noted: Routine testing is not recommended unless prompted by a change in circumstance such as the identification of a confirmed COVID-19 case in the facility. Under the heading of Documentation of Testing, the memo indicated that facilities must demonstrate compliance with the testing requirements. Upon identification of a new COVID-19 case in the facility (i.e. outbreak), the facility was to document the date the case was identified, the date that all other residents and staff were tested, the dates the staff and residents who were negative were retested, and the results of all tests. All residents and staff that tested negative were expected to be retested until testing identified no new cases of COVID-19 infection among staff or residents for a period of at least fourteen days since the most recent positive result. The facility was asked several times on 01/21/21 and 01/22/21, to provide documented evidence of compliance. No supporting documentation verifying adherence to the requirements of QSO-20-38 was provided at the time of the survey. . 105721 Page 2 of 4 105721 01/22/2021 Cedar Hill Nursing and Rehab Center 5888 Blanding Blvd Jacksonville, FL 32244

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to maintain an effective pest control program to ensure it was free of pests and rodents. Live roaches were observed in the facility's conference room, ice cream parlor, the hall outside of the chapel and in the facility's kitchen between 01/19/2021 and 01/22/2021. This practice had the potential to affect more than an isolated number of residents. Residents Affected - Some The findings include: On 01/19/21 at 7:19 am, a cockroach was observed crawling on the conference room floor. On 01/19/2021 at 11:12 am, a cockroach was observed crawling on the wall in the ice cream parlor area of the facility. (Photographic evidence obtained) Throughout the four-day survey from 01/19/21 through 01/22/21, residents were randomly observed sitting in the facility's ice cream parlor. On 01/20/2021 at 1:33 pm during an interview with the Medical Records Director, a live cockroach fell from the ceiling onto the handrail in the hallway outside of the chapel. The Medical Records Director jumped away from the handrail and confirmed it to be a live cockroach. She stated the facility had been having problems with pests. Residents were randomly observed using the handrails throughout the four-day survey. On 1/22/2021 at 11:58 am during an observation of meal assembly and food temperatures in the kitchen, a cockroach was observed crawling up the wall behind the stove where food was being cooked. (Photographic evidence obtained) The Administrator, also present in the kitchen, was alerted and also observed what was confirmed to be a live cockroach. He immediately grabbed an unidentified object in his hand and attempted to catch/kill the roach, but was unsuccessful. During an interview on 01/22/2021 at 12:05 pm, Employee K, Kitchen Supervisor, was made aware of the cockroach sighting. She stated pest control was recently in the facility, but she could not provide an exact date. She stated pest sightings were reported to administration and recorded in a pest sighting log. The Administrator, who was also present during this interview, confirmed this. He was asked to provide a copy of the facility's pest control contract and pest sighting log. On 01/22/2021 at 12:50 pm, prior to exiting the kitchen, the Administrator was reminded to provide the survey team with a copy of the requested pest control documents. He acknowledged the request. On 1/22/2021 at 3:08 pm, the pest control contract and pest sighting log were again requested from the Administrator. He acknowledged the request. At the time of the Exit Conference held on 1/22/2021 at 7:07 pm, the Administrator had still not provided the requested documentation. On 02/02/2021 at 4:58 pm, eleven days after the survey exit, the facility's Director of Operations emailed the following documents to the field office for consideration during supervisory review of the survey kit: Pest Control Inspection Report, dated 12/07/2020: 105721 Page 3 of 4 105721 01/22/2021 Cedar Hill Nursing and Rehab Center 5888 Blanding Blvd Jacksonville, FL 32244

F 0925 Level of Harm - Minimal harm or potential for actual harm No issues upon service, inspected and treated appropriate areas per service contract, interior/exterior pest control. Today I completed your monthly pest control service. Routine monthly interior/exterior pest control service documented that was targeted at rats. Exterior fluid application was targeted at general household pests. Pest Activity: None noted Residents Affected - Some Pest Control Inspection Report, dated 12/15/2020: Today, areas treated according to interior rotation were bathrooms and breakrooms, common areas and doorways and service to the kitchen. Residual application to doorways as well as bathrooms and breakroom baited and dusted. Kitchen was serviced by using residual dusts and bait. Also, once activity was noticed, I proceeded to use a flushing aerosol to draw pests out. Eliminated multiple German cockroaches in kitchen on main cook line. Conditions/Observations: Food debris underneath main cook line steamer and oven also has grease buildup. These sanitation issues are conducive to pest activity. Food debris was observed on flooring. This condition is an attractant to pests and rodents. Flies and other pests will result unless removed. An extensive cleaning and removal of food debris is needed to accomplish a pest-free environment. Areas Applied: Kitchen Target Pests: None Pest Control Inspection Report, dated 01/08/2021: Commercial Pest Control - Trouble Call Cross Care has roaches in their kitchen. Multiple German cockroaches coming out of the walls behind FRP board siding. Working with [facility maintenance employee] to schedule a clean out with multiple technicians. Product application targeting general household pests. Conditions/Observations: None noted Pest Activity: None noted Pest Control Inspection Report, dated 01/19/2021: Routine visit indicated. General Comments: No issues upon service. Inspected and treated appropriate areas per service contract. Interior/exterior pest control. Common areas, bathrooms, empty rooms on one wing and doorways. Today I completed your every two week pest control service. Conditions/Observations: None (three products applied) Product Application targeting none, ants and roaches. Pest Activity: (page was cut off.) A review of the above documentation revealed an ineffective pest control program, due in part, to the facility's failure to maintain cleanliness in the kitchen. The Pest Control contract and copies of the Pest Sighting log were not provided to the field office for review. . 105721 Page 4 of 4