Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Hill Nursing And Rehab Center during CMS and state inspections, most recent first.
The facility failed to implement a comprehensive water management program to prevent Legionella growth, risking residents' health. The program lacked annual reviews, control measures, and testing protocols. Staff interviews revealed a lack of training and adherence to policies, contributing to the deficiency.
The facility's kitchen was found to have significant sanitation and food safety deficiencies, including roaches in the oven, standing water, and uncovered drains with biofilm and gnats. Staff interviews revealed a lack of awareness and action regarding these issues, with missing drain covers not addressed for several months. The facility's policy on maintaining clean and sanitary food service equipment was not followed.
The facility failed to maintain the walk-in freezer door in safe operating condition, as it would not close completely, potentially leading to food safety issues. Despite being aware of the problem, the Certified Dietary Manager had not notified maintenance, and the Director of Maintenance was unsure of the next steps. This is a violation of the facility's policy and the 2022 Food Code.
The facility's pest control program was ineffective, as live cockroaches were observed in several resident rooms, a nurses' station, and the kitchen. Despite weekly pest control services, residents reported frequent sightings of cockroaches, and staff were unaware of the ongoing issue. The facility's pest control logs and policy were not sufficient to address the infestation.
The facility failed to provide a clean and comfortable environment for residents, as several were observed without pillowcases on their beds. Despite the standard bed-making process requiring pillowcases, a shortage was noted by staff, including a CNA and the Director of Laundry. Inventory checks confirmed the lack of pillowcases across various units, contrary to the facility's Admission Agreement, which includes linens and bedding in routine care.
The facility failed to maintain a sanitary and comfortable environment, with observed damage in several resident rooms, including holes in walls and missing base cove molding. Despite a policy requiring regular maintenance checks, necessary repairs were not made, and the Director of Housekeeping was unaware of the damage.
Inadequate Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive water management program aimed at reducing the risk of Legionella and other opportunistic pathogens in its water system, which is crucial for the safety of its 116 residents. These residents, who may have weakened immune systems or chronic conditions, are at risk for Legionnaires' Disease if exposed to Legionella bacteria. The facility's water management program binder included a guide from the CDC but lacked documentation of an annual review or evidence of designated staff performing necessary inspections and monitoring. The program did not include control measures or specify testing protocols, acceptable ranges for control measures, or documented results of testing for disinfectant levels. There was no verification or validation to ensure the program's effectiveness. The water flow chart was outdated and did not identify potential growth areas for Legionella. Water temperature logs showed temperatures conducive to Legionella growth, and there was no verification of chemical disinfectant levels in the water system. Interviews with the Director of Housekeeping and Laundry and the Director of Maintenance revealed a lack of training and adherence to the water management program. The Director of Maintenance had not conducted reviews or testing since his hiring, and the Director of Housekeeping and Laundry admitted to not following the policy and procedure. The facility's policy outlined the need for regular inspections, monitoring, and documentation, but these were not being implemented, leading to the deficiency.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen, as observed during a survey. During a kitchen tour, surveyors found two roaches inside the facility's oven, standing water in the drain located in the cook area, and an uncovered drain filled with biofilm and gnats near the walk-in refrigerator. These unsanitary conditions were documented with photographic evidence. On a follow-up visit, live roaches were again observed in the oven, along with a rust-like film and food debris. The uncovered drain continued to have biofilm and gnats, and another drain behind the cook area was filled with a dark fluid substance. Interviews with staff revealed a lack of awareness and action regarding these issues. A dietary aide acknowledged the missing drain covers but was not consistently aware of the standing water. Another staff member was unaware of the missing covers and standing water, indicating that issues were reported to the Certified Dietary Manager (CDM) or maintenance when equipment malfunctioned. The CDM was aware of the missing drain covers but had not yet notified maintenance. The Director of Maintenance was also aware of the missing covers for several months but had not yet procured replacements. The facility's policy requires that food service equipment be clean, sanitary, and in proper working order, which was not adhered to in this case.
Failure to Maintain Kitchen Equipment in Safe Condition
Penalty
Summary
The facility failed to maintain kitchen equipment in safe operating condition, specifically the walk-in freezer door located inside the walk-in refrigerator. During a kitchen tour, it was observed that the freezer door would not close completely after several attempts, which could potentially lead to thawing or partial thawing of frozen food items. This issue was observed on multiple occasions, with photographic evidence obtained to support the findings. The facility's policy and procedure require that food service equipment be clean, sanitary, and in proper working order, and that requests for maintenance or repairs be submitted as needed. Interviews with staff revealed that the issue with the freezer door had been known for some time. Dietary Aide F and another staff member stated that malfunctioning kitchen equipment was reported to maintenance or the Certified Dietary Manager (CDM). However, the CDM admitted to being aware of the problem but had not yet notified maintenance about the freezer door. The Director of Maintenance was informed of the issue months ago but was unsure of the next steps to take. The facility's failure to address the malfunctioning freezer door is a violation of the 2022 Food Code, which requires equipment to be maintained in good repair and proper adjustment.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to ensure the effectiveness of its pest control program, as evidenced by the presence of live cockroaches in multiple areas. Observations conducted from August 6 to August 9, 2024, revealed live cockroaches in four resident rooms on the South Unit, at one of the nurses' stations, and in the kitchen. Photographic evidence was obtained during these observations. Interviews with residents confirmed frequent sightings of cockroaches, with one resident stating that he had never seen his room sprayed for pests. The Director of Rehabilitation and the Certified Dietary Manager (CDM)/Director of Housekeeping and Laundry were both interviewed and observed live cockroaches during the survey. The CDM confirmed that the pest control service was provided weekly, but was unaware of the ongoing cockroach activity until the survey findings were shared. The facility's pest control logs and service inspection reports indicated regular pest control services, including weekly call-back services for resident rooms and monthly services for common areas, but these measures were ineffective in controlling the cockroach infestation. The facility's policy and procedure for pest control services outlined a program for controlling insects and rodents, with responsibilities assigned to the administrator and maintenance department. Staff were instructed to report live pest sightings, which were to be documented in a pest control log. Despite these procedures, the presence of cockroaches persisted, indicating a deficiency in the facility's pest control management and execution of its policy.
Deficiency in Providing Pillowcases for Residents
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for four residents, as observed during a survey. Specifically, these residents were missing pillowcases on their beds. Observations were made over several days, noting that residents were resting on pillows without pillowcases. One resident expressed discomfort and mentioned having requested a pillowcase from the staff without success. The facility's linen carts were repeatedly found lacking pillowcases, indicating a shortage. Interviews with staff, including a CNA and the Director of Laundry, revealed that there was a known shortage of pillowcases. The CNA described the standard bed-making process, which includes using a pillowcase, but acknowledged the shortage. The Director of Laundry explained the ordering process for linens and noted that an inventory check showed a low stock of pillowcases. The inventory review confirmed the shortage across various units, with some units having no pillowcases at all. The facility's Admission Agreement stated that linens and bedding are included in the routine care provided to residents.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable physical environment for residents, staff, and the public, as evidenced by observations of damage in several resident rooms. Specifically, holes in walls, missing base cove molding, and broken or missing closet door panels were noted in four rooms on the South Unit. These deficiencies were identified during facility tours conducted over several days, with photographic evidence obtained to document the issues. Despite the facility's policy requiring regular room rounds and maintenance logs to address such issues, the necessary repairs had not been made by the time of the final observation. During an interview, the Director of Housekeeping acknowledged being unaware of the damage and stated that there was no capital improvement plan in place. She mentioned that she communicated repair needs to the management company, which provided the necessary resources for repairs. The facility's policy outlined that the Maintenance Director or designee should conduct room rounds multiple times per month and prioritize repairs based on findings. However, the observed damage indicated a failure to adhere to these procedures, resulting in an environment that could negatively impact residents' enjoyment and safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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| Westside Oaks Rehabilitation & Nursing Center | 2.6 mi | ★★★★★ | 19 | 4 |
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| Vivo Healthcare Orange Park | 4.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.