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, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 105721 Printed: 05/28/2026 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 105721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hill Nursing and Rehab Center 5888 Blanding Blvd Jacksonville, FL 32244 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)