Concordia at the Cedars

In the surveyor’s words

From the most serious findings on record at Concordia at the Cedars, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Apr 20, 2021

  Based on a review of observations, facility policies, documentation, facility line listing of COVID-19 reporting and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during a COVID-19 outbreak in the facility. The facility cohorted positive and negative residents together, cohorted unvaccinated new admissions with existing residents, and failed to properly quarantine the possibly exposed existing residents from unexposed residents in the facility. […]

• Actual harm, isolatedF760Apr 20, 2021

  Based on clinical record review, interview, review of a facility incident report review and policies, it was determined that the facility failed to ensure the resident was free of significant medication errors, causing harm and requiring the resident to need additional medication and observation to manage symptoms for one of 6 residents reviewed (Resident R75). Findings include: The facility policy, Orders, dated 12/2015, and reviewed 4/14/2021, specified persons authorized to write orders on the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders are then transcribed into the electronic, medical record by the unit clerks and/or Licensed Nurses. […]

• No harm, potential for more than minimal, widespreadF812Mar 28, 2024

  Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to serve food/beverages in accordance with professional standards for food safety on one of one nursing units. (3rd Floor Nursing Unit) Findings include: Review of the facility policy, Food Safety Requirements, dated 1/28/24, indicated food will be distributed and served in accordance with professional standards for food service safety. Foods and beverages shall be distributed in a manner to prevent contamination. Observation of the lunch meal of the 3rd Floor nursing unit, on 3/27/28, at 11:40 a.m. through 12:40 p.m., revealed the following: At 11:40 a.m. Residents were served meals from the steam table in the kitchenette to the tables in the dining room. […]

• No harm, potential for more than minimal, widespreadF880Apr 21, 2022

  Based on observations, review of clinical records, facility policies, and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing implement diagnostic and preventative measures timely, to address an outbreak of gastrointestinal (GI, relating to the stomach and the intestines) illness for 24 of 48 residents (Residents R1, R5, R8, 59, R10, R11, R12, R13, R14, R15, R19, R20, R22, R24, R34, R42, R45, R47, R52, R157, R158, R159, R161, and R162) and failed to maintain infection control practices during a dressing change for one of two residents (Resident R4) including the proper wearing of Personal Protective Equipment (PPE) with a resident identified as being in isolation for the GI outbreak identified. […]

• No harm, potential for more than minimal, widespreadF835Apr 20, 2021

  Based on a review of job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper infection control procedures were followed to protect residents from COVID-19 disease and the facility failed to ensure the residents were free from significant medication errors. Findings include: The job description for the NHA specified that the NHA was responsible for managing all aspects of the Skilled Nursing within [NAME]'s Continuing Care Retirement Community environment including clinical, financial, operational, quality, compliance, human resources, leadership and risk management aspects. […]