Pennsylvania Department of Health
 CEDARWOOD REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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CEDARWOOD REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are  126 surveys for this facility. Please select a date to view the survey results.

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CEDARWOOD REHABILITATION & HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a complaint survey completed on June 4, 2024, it was determined that Cedarwood Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:







Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that insulin was administered timely for two of four residents reviewed (Residents 1, 4), and failed to provide medications as ordered by the physician for one of four residents reviewed (Resident 1). Findings include:The facility's policy for medication administration, dated November 30, 2023, revealed that medications were to be administered within one hour of their prescribed time, unless otherwise specified.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 9, 2024, indicated that the resident was cognitively intact, received insulin, and had diagnoses that included diabetes.Physician's orders for Resident 1, dated October 3, 2023, included and order for the resident to receive 15 units of Basaglar (insulin) subcutaneously (tissue just beneath the skin) one time a day and at bedtime, and a physician's order, dated May 7, 2024, included an order for the resident to receive 20 units of Basaglar subcutaneously two times a day for diabetes.The resident's Medication Administration Record (MAR) for April and May 2024 revealed that Resident 1 received Basaglar (scheduled for 8:00 a.m.) on April 8 at 9:15 a.m., April 18 at 11:40 a.m., April 30 at 9:54 a.m., May 2 at 10:33 a.m., May 3 at 9:17 a.m., May 6 at 11:26 a.m., May 8 at 10:07 a.m., May 20 at 9:21 a.m., May 24 at 9:18 a.m., and May 30, 2024 at 9:13 a.m., and received Basaglar (scheduled for 8:00 p.m.) on April 8 at 9:38 p.m., April 15 at 9:07 p.m., April 20 at 10:08 p.m., April 26 at 9:58 p.m., April 28 at 9:06 p.m., May 7 at 9:23 p.m., May 28 at 1:46 a.m., and May 30, 2024 at 9:29 p.m.Nursing notes for Resident 1, dated April 27, 2024, at 10:04 p.m. and May 28, 2024, at 7:52 a.m. revealed that Basaglar was not available from the pharmacy.The resident's MAR for May 2024 revealed that Basaglar was not administered on May 27, 2024, at 8:00 p.m. and May 28, 2024, at 8:00 a.m.A quarterly MDS assessment for Resident 4, dated May 2, 2024, indicated that the resident was cognitively intact, received insulin, and had diagnoses that included diabetes.Physician's orders for Resident 4, dated April 7, 2022, included an order for the resident to receive 35 units of Glargine (insulin) subcutaneously in the evening for diabetes.The resident's Medication Administration Record (MAR) for April and May 2024 revealed that the resident received Glargine (scheduled for 8:00 p.m.) on April 1 at 10:02 p.m., April 5 at 9:38 p.m., April 14 at 9:58 p.m., April 15 at 9:38 p.m., April 20 at 9:48 p.m., April 26 at 9:22 p.m., May 2 at 10:28 p.m., May 10 at 10:56 p.m., May 13, at 9:33 p.m., May 18, at 9:39 p.m., and May 24, at 9:34 p.m.Interview with the Director of Nursing on May 31, 2024, confirmed that Resident 1 and 4 did not receive their insulin timely according to the facility's policy and Resident 1 did not receive Basaglar as ordered on May 27, 2024, at 8:00 p.m. and on May 28, 2024, at 8:00 a.m.28 Pa. Code 211.12(d)(3)(5) Nursing Services.
 Plan of Correction - To be completed: 07/10/2024

1. Unable to retroactively correct the insulin administration times for residents 1 and 4. Unable to provide insulin that was unavailable for resident 1 for dates listed. Residents 1 and 4 are receiving insulin at the correct administration times. Resident 1 has insulin available for administration.

2. Director of Nursing or Designee will conduct an initial audit of current residents with active insulin orders were reviewed for administration at proper times. Current residents with insulin orders were reviewed for sufficient insulin supply available.

3. Director of Nursing or Designee will re-educate licensed staff on medication administration policy and reordering of insulin timely.

4. Director of Nursing or Designee will audit five residents receiving insulin for accuracy of administration and availability of insulin weekly for four weeks and 10 residents monthly for two months thereafter. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

5. Date of compliance is 7/10/24.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:







Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day on the day shift for 18 of 21 days, failed to ensure a minimum of one LPN per 30 residents on the evening shift for two of 21 days, and failed to ensure a minimum of one LPN per 40 residents on the overnight shift for one of 21 days (24-hour periods) reviewed.Review of facility census data indicated that on May 5, 2024, the facility census was 98, which required 3.92 LPNs during the day shift. Review of the nursing time schedules revealed 3.00 LPNs worked on the day shift on May 5, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 6, 2024, the facility census was 97, which required 3.88 LPNs during the day shift. Review of the nursing time schedules revealed 3.38 LPNs worked on the day shift on May 6, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 7, 2024, the facility census was 96, which required 3.84 LPNs during the day shift. Review of the nursing time schedules revealed 3.38 LPNs worked on the day shift on May 7, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 9, 2024, the facility census was 95, which required 3.80 LPNs during the day shift. Review of the nursing time schedules revealed 3.44 LPNs worked on the day shift on May 9, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 10, 2024, the facility census was 96, which required 3.84 LPNs during the day shift. Review of the nursing time schedules revealed 3.38 LPNs worked on the day shift on May 10, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 11, 2024, the facility census was 96, which required 3.84 LPNs during the day shift. Review of the nursing time schedules revealed 3.38 LPNs worked on the day shift on May 11, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 12, 2024, the facility census was 94, which required 3.76 LPNs during the day shift. Review of the nursing time schedules revealed 3.22 LPNs worked on the day shift on May 12, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 13, 2024, the facility census was 95, which required 3.80 LPNs during the day shift. Review of the nursing time schedules revealed 3.00 LPNs worked on the day shift on May 13, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 14, 2024, the facility census was 92, which required 3.68 LPNs during the day shift. Review of the nursing time schedules revealed 3.00 LPNs worked on the day shift on May 14, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 15, 2024, the facility census was 94, which required 3.76 LPNs during the day shift. Review of the nursing time schedules revealed 3.47 LPNs worked on the day shift on May 15, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 16, 2024, the facility census was 96, which required 3.84 LPNs during the day shift. Review of the nursing time schedules revealed 3.56 LPNs worked on the day shift on May 16, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 17, 2024, the facility census was 95, which required 3.80 LPNs during the day shift. Review of the nursing time schedules revealed 3.75 LPNs worked on the day shift on May 17, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 18, 2024, the facility census was 96, which required 3.84 LPNs during the day shift. Review of the nursing time schedules revealed 3.19 LPNs worked on the day shift on May 18, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 19, 2024, the facility census was 95, which required 3.80 LPNs during the day shift. Review of the nursing time schedules revealed 3.50 LPNs worked on the day shift on May 19, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 20, 2024, the facility census was 94, which required 3.76 LPNs during the day shift. Review of the nursing time schedules revealed 3.00 LPNs worked on the day shift on May 20, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 22, 2024, the facility census was 94, which required 3.76 LPNs during the day shift. Review of the nursing time schedules revealed 3.00 LPNs worked on the day shift on May 22, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 22, 2024, the facility census was 94, which required 3.13 LPNs during the day shift. Review of the nursing time schedules revealed 3.09 LPNs worked on the evening shift on May 22, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 23, 2024, the facility census was 95, which required 3.80 LPNs during the day shift. Review of the nursing time schedules revealed 3.00 LPNs worked on the day shift on May 23, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 23, 2024, the facility census was 95, which required 3.17 LPNs during the day shift. Review of the nursing time schedules revealed 3.00 LPNs worked on the evening shift on May 23, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 23, 2024, the facility census was 95, which required 2.38 LPNs during the day shift. Review of the nursing time schedules revealed 2.34 LPNs worked on the night shift on May 23, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Review of facility census data indicated that on May 25, 2024, the facility census was 95, which required 3.80 LPNs during the day shift. Review of the nursing time schedules revealed 3.06 LPNs worked on the day shift on May 25, 2024. No additional excess higher-level staff were available to compensate for this deficiency.Interview with the Nursing Home Administrator on June 4, 2024, at 1:06 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed.
 Plan of Correction - To be completed: 07/10/2024

1. Facility cannot retroactively correct staffing ratio.
2. Director of Nursing or Designee will conduct an initial audit of the past two weeks schedule to determine if LPN ratio is in compliance. The facility will continue to take measures to adequately provide LPN staff to ensure the needs of the residents are met. These measures include, continuing our retention/culture committee, increased advertising efforts, and sign on bonuses.
3. Director of Nursing or Designee will re-educate the scheduler and nursing administration team on the proper LPN staffing ratios. The facility will hold daily labor meetings to verify ratios are made.
4. Director of Nursing or Designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
5. Date of compliance is 7/10/24.


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