Cedarwood Rehabilitation & Healthcare Center

In the surveyor’s words

From the most serious findings on record at Cedarwood Rehabilitation & Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 27, 2022

  Based on a review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that supervision and adequate interventions were in place to prevent elopement while out of the facility for an appointment, which threatened the resident's safety for one of 56 residents reviewed (Resident 47) who was identified as at risk for elopement. The facility's failure created a situation in which the resident obtained and used illegal drugs, which placed the resident in immediate jeopardy of the likelihood of serious bodily injury, harm or death. This deficiency was cited as past non-compliance. […]

• Actual harm, isolatedF600Apr 17, 2025

  Based on review of policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Resident 2), resulting in harm due to a fall with fractures. This deficiency is being cited as past non-compliance. Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation dated January 30, 2025, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. […]

• Actual harm, isolatedF689Apr 17, 2025

  Based on review of investigation reports and clinical records, as well as staff interviews, it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of four residents reviewed (Resident 2) who required two staff for bed mobility, resulting in a fall with fractures. This deficiency is being cited as past non-compliance. Findings include: Admission paperwork for Resident 2, dated April 4, 2025, revealed that the resident was admitted to the facility on [DATE], after having fallen at home and suffering a hip fracture, which required surgery on March 30, 2025. The resident was alert with slight confusion and required extensive assistance from two staff members for care, including bed mobility. […]

• Actual harm, isolatedF580Dec 1, 2023

  Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the physician was notified timely of a change in condition, resulting in hospitalization and death for one of 11 residents reviewed (Resident 1). Findings include: The facility's policy regarding physician notification, dated February 23, 2023, indicated that the physician would be notified in a timely manner when a change in condition involving the resident occurred. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 29, 2023, revealed that the resident was cognitively intact, required only supervision for daily care tasks, and was continent of bowel and bladder. […]

• Actual harm, isolatedF658Dec 1, 2023

  Based on review of the Pennsylvania Nurse Practice Act, facility policies, residents' clinical records, and a resident's hospital records, as well as staff interviews, it was determined that the facility failed to ensure that a resident was assessed after a change in condition for one of 11 residents reviewed (Resident 1), resulting in a delay in sending the resident to the hospital for a serious medical condition. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing… […]