Pennsylvania Department of Health
CEDARWOOD REHABILITATION & HEALTHCARE CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 45 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on January 14, 2025, it was determined that Cedarwood Rehabilitation and Healthcare Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(c)(1), 416.54(c)(1), 418.113(c)(1), 441.184(c)(1), 482.15(c)(1), 483.475(c)(1), 483.73(c)(1), 484.102(c)(1), 485.542(c)(1), 485.625(c)(1), 485.68(c)(1), 485.727(c)(1), 485.920(c)(1), 486.360(c)(1), 491.12(c)(1), 494.62(c)(1) STANDARD Names and Contact Information:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1).

[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.

*[For RNHCIs at §403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at §416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at §418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at §484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at §486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).

Observations:
Name: - Component: -- - Tag: 0030

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to include names and contact information.

Findings include:

1. Interview and documentation review of the facility EP plan on January 14, 2025, at 9:30 a.m., revealed the EP Plan did not include updated and accurate names and contact information for (i) Staff and (ii) Resident physicians.

Interview with the Director of Nursing and Maintenance Director on January 14, 2025, at 2:30 p.m., confirmed the listed EP plan deficiency.

Plan of Correction - To be completed: 02/18/2025

1. The facility EP plan has been updated to accurately reflect the proper staff and physician contact information.

2. Maintenance director or designee will verify it is updated if information changes.

3. Nursing home administrator or designee will re-educate the maintenance director on accurately and timely updating the EP plan as contact information changes.

4.Maintenance director or designee will audit the EP plan monthly for the next three months to verify contact information is accurate. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

Date of compliance will be 2/18/2025.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 050802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 14, 2025, it was determined that Cedarwood Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a four-story, Type II (222), fire-resistive structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Cooking Facilities:

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.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review, observation, and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of nine smoke compartments.

Findings include:

1. Observation and document review on January 14, 2025, at 8:55 a.m., revealed the facility lacked documentation for the semi-annual testing/maintenance of the kitchen fire suppression system, due to be performed between January-June 2024.

Interview with the Director of Nursing and Maintenance Director on January 14, 2025, at 2:30 p.m., confirmed the kitchen fire suppression system testing/maintenance deficiency.

Plan of Correction - To be completed: 02/18/2025

1. The facility will obtain documentation for the semi-annual testing/maintenance of the kitchen fire suppression system.

2. Maintenance director or designee will verify that semi-annual testing/maintenance of the kitchen fire suppression is completed and audited semi-annually.

3. Nursing home administrator or designee will re-educate the maintenance director of completing semi-annual testing/maintenance of the kitchen fire suppression timely.

4. Maintenance director or designee will audit that semi-annual testing/maintenance of the kitchen fire suppression is completed and audited semi-annually. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

Date of Compliance will be 2/18/2025

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of nine smoke compartments.

Findings include:

1. Observation on January 14, 2025, at 11:45 a.m., revealed two dirty/dusty sprinkler heads, located above the dryers in the Laundry Room. The amount of dirt/dust could affect the activation of the sprinkler head.

Interview with the Director of Nursing and Maintenance Director on January 14, 2025, at 2:30 p.m., confirmed the sprinkler system deficiency.

Plan of Correction - To be completed: 02/18/2025

1. Sprinkler heads identified have been cleaned.

2. Maintenance director or designee will conduct a facility audit to verify that sprinkler heads are free from dust.

3. Nursing home administrator or designee will re-educate the maintenance director on properly maintaining the sprinkler heads in the facility verifying they are free from dust.

4. Maintenance director or designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that the sprinkler heads are free from dust. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

Date of compliance will be 2/18/2025

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement