Inspection·August 9, 2024

F 0584 a pillowcase. The resident was not present to interview. Level of Harm - Minimal harm or potential for actual harm On 8/8/24 at 9:46 AM, an observation was made of Resident #102's bed linen, which was missing a pillowcase. The resident was not present to interview. Residents Affected - Few On 8/8/24 at 10:06 AM, the Director of Laundry was interviewed and stated she was responsible for ordering bed linens, which were ordered through a local linen company on the 15th of every month. She explained that she scanned an order request to the facility Advisor who oversaw the purchase of linens, and once a linen order was approved and submitted, it usually shipped to the facility within one week. She further explained that the CNAs were responsible for making the residents' beds, which was done first thing in the morning three times a week. Making a resident's bed included placing a fitted sheet over the mattress, followed by a chucks pad, a blanket (depending on the resident's preference) and a pillowcase over the pillow. She reported that this morning she noticed a shortage of washcloths and pillowcases. Laundry services staff made an inventory of bed linens and provided her with a status of the facility's stock prior to her ordering bed linens. She stated this morning she conducted a count of the bed linen inventory on the dirty laundry side and clean laundry side. She noticed the inventory was low and submitted an order for bed linens. She further explained that many residents were known to hoard linens, which could have been a factor laeding to the shortage of bed linens. A review of the laundry room inventory, dated 8/8/24, revealed that the facility had no pillowcases in the laundry room. A review of the Butterfly (memory care) unit, dated 8/8/24, revealed that the unit contained 12 pillowcases. A review of the South Wing 102 unit linen inventory, dated 8/8/24, revealed that the unit contained no pillowcases. A review of the South Wing 112 unit linen inventory, dated 8/8/24, revealed that the unit contained nine pillowcases. A review of the North Wing 212 unit linen inventory, dated 8/8/24, revealed that the unit contained one pillowcase. A review of the North Wing 226 unit linen inventory, dated 8/8/24, revealed that the unit contained 12 pillowcases. A review of the North Wing 237 unit linen inventory, dated 8/8/24, revealed that the unit contained two pillowcases. A review of the facility's admission Agreement revealed under Item #12: Routine care included in the per diem rate: (b) Linens and Bedding. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 2 of 13 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 08/09/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews, and facility policy and procedure review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Proper sanitation is important in health care settings to prevent the outbreak of foodborne illness. Nursing home residents are at risk for serious complications from foodborne illness due to their already compromised health status, and standing water, biofilm, and pests such as gnats and roaches are sources of contamination. The findings include: A kitchen tour was conducted on 8/6/24 at 10:24 AM. The facility's oven was opened for observation and two roaches were observed crawling inside. Standing water was observed in the drain located in the cook area in front of the steamer. A small drain on the floor in front of walk-in refrigerator was observed to be uncovered and filled with a biofilm slime-like substance around the lip of the drain. Gnats were observed moving around the lip of the uncovered drain. (Photographic evidence obtained) During a follow-up visit to the kitchen on 8/8/24 at 10:45 AM, another observation was made of live roaches crawling in the oven of the kitchen range. A rust-like film was on the inside of the kitchen oven, and food debris was observed on and in between the top part of the oven. Another observation was made of the small drain on the floor in front of walk-in refrigerator that was uncovered and filled with a biofilm slime-like substance around the lip of the drain. Gnats were observed moving around the lip of the uncovered drain. An observation was also made of a small drain behind the wall of the cook area, adjacent to the ice machine, that was uncovered and filled with a dark fluid substance. (Photographic evidence obtained) During an interview with Dietary Aide F on 8/9/24 at 1:44 PM, she stated she was aware that the floor drains were missing covers. When she was asked if she was aware of the standing water in the drainage area located in front of the steamer, she replied, Not always. Most of the time I drain water out of the steam well and it was working fine. She also stated when kitchen equipment was not functioning properly or standing water was observed, it was reported to maintenance. During an interview with [NAME] G on 8/9/24 at 1:48 PM, he stated he was not aware that the floor drains were missing covers. When he was asked if he was aware of the standing water in the drainage area located in front of the steamer, he replied, No, it is usally dry by the time I come in to work. A broom is used to clear the old food out and let water drain. He also stated when kitchen equipment was not functioning properly it was reported to the Certified Dietary Manager (CDM) or maintenance. During an interview with the Certified Dietary Manager (CDM)/Director of Housekeeping and Laundry on 8/9/24 at 3:45 PM, she stated she was aware that the floor drain covers were missing. She had not notified maintenance about the missing drain covers as of the time of this interview. She stated her plan was to notify maintenance regarding covers for the drains. The drains had to be measured and covers ordered. During an interview with the Certified Dietary Manager (CDM)/Director of Housekeeping and Laundry on 8/9/24 at 4:12 PM, she stated the kitchen's oven was not working. When the oven door was opened (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 3 of 13 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 08/09/2024 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)

F 0812 during the interview with the CDM, roaches were again observed crawling on the inside bottom of the oven. Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Maintenance on 8/9/24 at 5:10 PM, he stated he was aware that the floor drains were missing covers. They had been missing covers for a couple of months. He stated he planned to locate covers at plumbing locations. He further stated last week when they were having an issue with a drain line, a vendor came to the facility to address a build-up in the drain line and suggested that covers for the floor drains could be obtained locally from a store. Residents Affected - Some A review of the facility's policy and procedure titled Kitchen Equipment (dated 12/8 2022) revealed: Food service equipment will be clean, sanitary, and in proper working order. Procedure: 1. All equipment will be routinely cleaned and maintained in accordance with manufacturers' instructions . 4. Non-food contact equipment will be clean and free of debris. 5. Requests for maintenance or repairs are to be submitted to the Administrator and/or Maintenance Director as needed. (Copy obtained) Reference: 2022 Food Code, United States Food and Drug Administration. Chapter 4, Page 127 and 165. https://www.fda.gov (Accessed on 8/12/2024): Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils . (C) Non-Food-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Equipment. 4.501.11. Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 4 of 13 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 08/09/2024 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility record review, staff interview, and facility policy and procedure review, the facility failed to develop and implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water system for its current census of 116 residents. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. Residents Affected - Many Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program that must be based on nationally accepted standards. The program must include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. The findings include: From 8/6/24 through 8/9/24, a review of the facility's infection control and water management program was conducted. The facility water management program binder was produced. The binder contained a copy of the Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, A Practical Guide to Implementing Industry Standards. U.S. Department of Health and Human Services Centers for Disease Control and Prevention, dated 6/24/2021. (Copy obtained) During an interview with the Director of Housekeeping and Laundry on 8/9/24 at 10:22 AM, she confirmed that she supervised the maintenance program and was responsible for the facility's water management program. She stated the facility followed the U.S. Department of Health and Human Services Centers for Disease Control and Prevention guide. A review of the water management program binder revealed the program did not include documentation verifying that the facility had conducted an annual review of its water management program. There was no documented evidence to verify that a staff member had been designated to perform visual inspections for biofilm, checking disinfectant levels, or periodic flushing of pipes. The program did not include control measures, including points in the system where critical limits could be monitored, or where control could be applied, such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. It did not specify testing protocols, acceptable ranges for control measures, or documented results of testing of pH levels of disinfectant in the water. There were no confirmatory procedures, including verification steps to show that the program was being followed as written, or validation to show that the program was effective. The program binder contained a facility water flow chart, dated 7/28/17, that did not identify where Legionella or other opportunistic waterborne pathogens could grow and spread in the facility's water system. There was no documented evidence of monitoring areas of the water flow system that had the likelihood of developing Legionella. (Copy obtained) A review of the Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, A Practical Guide to Implementing Industry Standards guide revealed it read: Factors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 5 of 13 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 08/09/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many internal to buildings that can lead to Legionella growth: Water temperature fluctuations: Provide conditions where Legionella grows best (77°F-113°F); Legionella can still grow outside this range. A random review of the Water Temperature Logs dated 5/31/24 revealed that the water temperature on the 200 hall was 104 degrees Fahrenheit ('F). The water temperature for the 100 hall shower room was 104 'F. The 200 hall shower room water temperature was 107 'F. (Photographic evidence obtained) A review of a random Legionella Environmental Assessment Form, dated 5/15/24, revealed no documented verification of the chemical level of disinfectant in the potable water system. (Photographic evidence obtained) During an interview with the Director of Maintenance on 8/9/24 at 4:23 PM, he confirmed that he had received no training on the water management program and the review and testing of the water system had not been done since he was hired in March 2024. He had not been doing it. He had no testing kit for the disinfectant level in the water. He stated he did take the temperature of the water and logged it. During an interview with the Director of Housekeeping and Laundry on 8/9/24 at 4:35 PM, she confirmed that the testing of the water system had not been done on an annual basis. She stated she was responsible for the water management system. She stated she had telephoned a sister facility to find out what they should be doing. She stated, We aren't doing what they are doing. We aren't following the policy and procedure. A review of the facility's policy and procedure titled Legionella Risk Management Policy (Undated), revealed: The purpose of this policy is to ensure that as far as possible, all residents, staff and visitors of this facility are protected from the incidence of Legionnaire's disease. The facility's Quality Assurance/Performance Improvement Committee's role will be to ensure that the relevant testing is completed and documented and that up to date risk assessment is completed annually, and any concerns are addressed in a timely manner. It is the policy of this facility to ensure that appropriate precautions for the control of Legionella bacteria are identified through a Legionella risk assessment process, and appropriate control measures implemented to ensure, so far as reasonably practicable, the health, safety and welfare of residents, employees and others. The minimum standards to be met include: Preparing Legionella Risk Assessments; Preparation of an action plan for preventing or controlling the risk; Implementation, management, monitoring and recording of precautions to include regular inspections, microbiological monitoring, temperature checks and flushing; Appointment of a person or persons to be managerially responsible for the water system; and This policy applies to the water system including, hot and cold water supply systems, cooling towers, shower heads, ice machines, etc. It is very important to measure and document the current physical and chemical characteristics of the potable water, as this can help determine whether conditions are likely to support Legionella amplification. Plan a sampling strategy that incorporates all central hot water heaters/boiler at various points along each loop of the potable water system. Water temperature record sheets need to be filled out and kept within the log book. Hot water should be at least 50 'Celcius (122 'F) after a 1 minute flow, and cold water below 20 'C (68 'F) after 2 minutes flow. Failing temperatures should be reported for suitable action and retested until satisfactory. Reference: Legionnaires' disease is a serious type of pneumonia caused by bacteria, called Legionella, that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 6 of 13 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 08/09/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm live in water. Legionella can make people sick when they inhale contaminated water from building water systems that are not adequately maintained. Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, 6/24/2021. https://www.cdc.gov/legionella/water-system-maintenance/wmp-fact-sheet.html and https://www.cdc.gov/legionella/index.html Residents Affected - Many . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 7 of 13 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 08/09/2024 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)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, and facility policy and procedure review, the facility failed to maintain kitchen equipment in safe operating condition. The kitchen's freezer door would not close properly, leaving the possibility open for potential thawing or partial thawing of frozen food items. This could result in the outbreak of foodborne illness affecting residents who receive food from the facility's kitchen. Residents Affected - Some The findings include: A kitchen tour was conducted on 8/6/24 at 10:24 AM. The walk-in freezer door, located inside the walk-in refrigerator, would not close completely after several attempts to push the door closed to exit back into the walk-in refrigerator. Another observation was made on 8/8/24 at 10:25 AM of the walk-in freezer located inside the walk-in refrigerator. The door was not closed completely and would not close completely. (Photographic evidence obtained) During a follow-up visit to the kitchen on 8/8/24 at 10:45 AM, another observation was made of the walk-in freezer door not closing completely after several attempts to push the door closed. (Photographic evidence obtained) During an interview with Dietary Aide F on 8/9/24 at 1:44 PM, she stated when kitchen equipment was not functioning properly, it was reported to maintenance. During an interview with [NAME] G on 8/9/24 at 1:48 PM, he stated when kitchen equipment was not functioning properly it was reported to the Certified Dietary Manager (CDM) or maintenance. During an interview with the CDM on 8/9/24 at 3:45 PM, she stated she was aware that the freezer door did not close properly. She had not notified maintenance about the walk-in freezer door as of the time of this interview. She stated her plan was to notify maintenance regarding hinges for the freezer door. She planned to reach out to the vender regarding door hinges for the walk-in freezer door. During an interview with the Director of Maintenance on 8/9/24 at 5:10 PM, when he was asked if he was aware that the freezer door was not closing properly, he replied that the CDM notified him about that a few months ago. He was not sure of the next step to take to fix the freezer door. A review of the facility's policy and procedure titled Kitchen Equipment (dated 12/8 2022) revealed: Food service equipment will be clean, sanitary, and in proper working order. Procedure: 1. All equipment will be routinely cleaned and maintained in accordance with manufacturers' instructions . 4. Non-food contact equipment will be clean and free of debris. 5. Requests for maintenance or repairs are to be submitted to the Administrator and/or Maintenance Director as needed. (Copy obtained) Reference: 2022 Food Code, United States Food and Drug Administration. Chapter 4, Page 127 and 165. https://www.fda.gov (Accessed on 8/12/2024): Equipment. 4.501.11. Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 8 of 13 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 08/09/2024 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)

F 0908 Level of Harm - Minimal harm or potential for actual harm specifications. Durability and Strength 4-201.11: Equipment and utensils shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions. . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 9 of 13 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 08/09/2024 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy and procedure review, the facility failed to maintain the physical environment in a sanitary and comfortable manner based on the following: holes in walls, missing base cove molding, and broken and missing closet door panels in four (Rooms 120, 118, 121, and 117) of 66 resident rooms, all of which were located on the South Unit of the facility. These concerns could negatively impact residents' enjoyment of their environment as well as their safety. The findings include: From 8/6/24 through 8/9/24, tours of the facility were conducted at various times. room [ROOM NUMBER] was observed on 8/6/24 at 10:47 AM with wall damage behind the toilet in the bathroom and missing pieces of the closet door panels. (Photographic evidence obtained) room [ROOM NUMBER] was observed on 8/6/24 at 11:03 AM with wall damage and base cove molding damage under the A-bed, a gap in the base cove molding under the air conditioner, and wall damage the length of the air conditioning unit under the unit. (Photographic evidence obtained) room [ROOM NUMBER] was observed on 8/6/24 at 11:34 AM with the base cove molding missing along the wall near the clothes cabinet and chips of paint loose from the wall. (Photographic evidence obtained) room [ROOM NUMBER] was observed on 8/7/24 at 9:14 AM with wall damage and a gap in the base cove molding near the air conditioner unit. (Photographic evidence obtained) During a tour of the facility on 8/9/24 at 9:46 AM, the facility maintenance staff had not made repairs to the holes in the walls, closet doors, or base cove molding in the rooms identified above, observed on 8/6/24 and 8/7/24. During an interview with the Director of Housekeeping on 8/9/24 at 4:32 PM, she reviewed the photographs of rooms 120, 118, 121, and 117 with wall damage and stated she was unaware of the damage. She further stated there was no capital improvement plan, but she let the management company know what needed to be repaired, and the facility received what was needed to make the repairs. A review of the facility's policy and procedure titled Physical Environment - Room Repairs (effective date: 9/26/23), revealed: Policy: The center will ensure the residents have a safe, homelike, environment free from physical hazards. 1. To ensure a safe, homelike environment, the Maintenance Director, or designee, will complete room rounds 2-4 times per month. Findings from these rounds will be prioritized and the repairs made as indicated. 2. Apart from completing room rounds, a maintenance log is kept at the nurses' station for any repairs staff find need completed throughout the day. Staff are to put the maintenance request in the log, and the maintenance department will check the log throughout the day to complete the tasks. Any repairs requiring immediate attention are to be reported directly to the Maintenance Director or Administrator. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 10 of 13 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 08/09/2024 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)

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, facility pest control management documentation, and a review of the facility's policy and procedure, the facility failed to ensure that its pest control service was effective. Cockroaches were observed in four (Rooms 120, 118, 121, and 117) of 66 resident rooms (all on the South Unit), at one (South Unit) of two nurses' stations, and in the kitchen. An ineffective pest control program can result in the transmission of disease/infection. Residents Affected - Some The findings include: From 8/6/24 through 8/9/24, tours of the facility were conducted at various times. Live cockroaches were observed in room [ROOM NUMBER] on 8/6/24 at 10:47 AM. (Photographic evidence obtained). Live cockroaches were observed in room [ROOM NUMBER] on 8/6/24 at 11:03 AM. (Photographic evidence obtained) Live cockroaches were observed in room [ROOM NUMBER] on 8/6/24 at 11:34 AM. (Photographic evidence obtained) Live cockroaches were observed in room [ROOM NUMBER] on 8/7/24 at 9:14 AM. (Photographic evidence obtained) During an interview with Resident #58 (room [ROOM NUMBER]) on 8/6/24 at 11:03 AM, he was observed lying in his bed. A live cockroach was observed crawling on the wall behind the headboard of his bed. Resident #58 stated he saw live cockroaches in his room all the time. He had never seen anyone spray his room for pests. During an interview with Resident #89 (room [ROOM NUMBER]) on 8/6/24 at 11:34 AM, he was observed lying in his bed. A live cockroach crawled across the floor in the middle of his room. He looked at the roach and acknowledged that it was a live roach. He was not sure if his room had been sprayed for pests. He stated he would appreciate it if they would do so. During an interview with the Director of Rehabilitation on 8/8/24 at 9:46 AM, a live cockroach was observed crawling on floor near the nurses' station on the South Unit. The roach crawled under a cabinet before a photograph could be taken. The Director of Rehabilitation saw the cockroach and stated, Well, it's not as bad as it used to be. During a follow-up kitchen tour on 8/8/24 at 10:45 AM, live roaches were observed in the oven of the kitchen range. During an interview with the Certified Dietary Manager (CDM)/Director of Housekeeping and Laundry on 8/9/24 at 4:12 PM, she stated the kitchen's oven was not working. When the oven door was opened during the interview with the CDM, roaches were again observed crawling on the inside bottom of the oven. During an interview with the CDM/Director of Housekeeping and Laundry on 8/9/24 at 4:32 PM, she confirmed that the contracted pest control service was provided weekly. She was then made aware of the observations of live cockroach activity in the facility. She reviewed the photographs of the rooms with the roach sightings and stated she would contact the pest control company. A review of the facility's Service Inspection Report, dated 7/31/24, revealed that the contracted pest control company noted weekly call-back service for covered pests (Resident rooms per request/logbook). (Copy obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 11 of 13 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 08/09/2024 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)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's Service Inspection Report, dated 7/17/24, revealed that the contracted pest control company noted monthly service for common areas, the kitchen, and dining areas. Treated kitchen areas, dining areas, and nurses' stations. Weekly call-back service for covered pests (Resident rooms per request/logbook). Target pests: roaches. (Copy obtained) A review of the facility's Service Inspection Report, dated 7/2/24, revealed that the contracted pest control company noted weekly call-back service for covered pests (Resident rooms per request/logbook). (Copy obtained) A review of the facility Service Inspection Report, dated 6/27/24, revealed that the contracted pest control company noted weekly call-back service for covered pests (Resident rooms per request/logbook). Treated kitchen areas, dining areas, and nurses' stations. (Copy obtained) A review of the facility's Service Inspection Report, dated 6/19/24, revealed that the contracted pest control company noted monthly service for common areas, kitchen, and dining areas. Treated kitchen areas, dining areas, and nurses' stations. Weekly call-back service for covered pests (Resident rooms per request/logbook). Target pests: roaches. (Copy obtained) A review of the facility's Service Inspection Report, dated 6/13/24, revealed that the contracted pest control company noted weekly call-back service for covered pests (Resident rooms per request/logbook). Treated kitchen areas, dining areas, and nurses' stations. (Copy obtained) A review of the facility's Service Inspection Report, dated 5/31/24, revealed that the contracted pest control company noted weekly call-back service for covered pests (Resident rooms per request/logbook). Monthly service for common areas, kitchen, and dining areas. (Copy obtained) A review of the facility's Service Inspection Report, dated 5/23/24, revealed that the contracted pest control company noted weekly call-back service for covered pests (Resident rooms per request/logbook). Treated kitchen areas, dining areas, and nurses' stations. (Copy obtained) A review of the facility's Service Inspection Report, dated 5/16/24, revealed that the contracted pest control company noted monthly service for common areas, kitchen, and dining areas. Treated kitchen areas, dining areas, and nurses' stations. Weekly call-back service for covered pests (Resident rooms per request/logbook). Target pests: roaches. (Copy obtained) A review of the facility's Service Inspection Report, dated 5/4/24, revealed that the contracted pest control company noted weekly call-back service for covered pests (Resident rooms per request/logbook). Monthly service for common areas, kitchen, and dining areas. (Copy obtained) A review of the facility's Service Inspection Report, dated 4/30/24, revealed that the contracted pest control company noted weekly call-back service for covered pests (Resident rooms per request/logbook). Monthly service for common areas, kitchen, and dining areas. (Copy obtained) A review of the pest control log for the South Unit of the facility revealed that cockroaches were reported to have been seen in room [ROOM NUMBER] on 6/18/24, and rooms [ROOM NUMBERS] on 5/28/24. Roaches were reported to have been seen in rooms 101, 103, 106, 109, 112, 116, 117, 118, 119, 120, 132, and 133 from 1/16/24 through 8/6/24. (Copy obtained) A review of the pest control log for the North Unit of the facility revealed that cockroaches were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 12 of 13 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 08/09/2024 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)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reported to have been seen in rooms 212, 213, 214, 224, 227, 228, 231, 233, 234, 235, 236, and 237 from 1/16/24 through 8/6/24. One line on the log read: All rooms on North 2. (Copy obtained) A review of the facility's policy and procedure titled Pest Control Services (effective date: 12/8/23), revealed: Policy: A program will be established for the control of insects and rodents within the facility. Procedure: 1. The administrator coordinates with the Maintenance Department to arrange pest control services on a monthly basis, or as needed. 3. Staff should report to the Administrator/Maintenance Department sightings of live pests. 4. Live pest sightings are documented in the pest control log. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105721 If continuation sheet Page 13 of 13