Pennsylvania Department of Health
CONCORDIA AT THE CEDARS
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CONCORDIA AT THE CEDARS
Inspection Results For:

There are 137 surveys for this facility. Please select a date to view the survey results.

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CONCORDIA AT THE CEDARS - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, completed on February 26, 2026, it was determined that Concordia at the Cedars was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulation as they relate to the Health portion of the survey process.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§ 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 review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of decreased Capillary Blood Glucose (CBG) levels for two of eight residents reviewed (Residents R3 and R5).

Findings include:

The Centers for Disease Control define diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds.

Review of the facility policy "Hypoglycemia Management" reviewed 1/16/25 and 1/15/26, indicated the facility will identify residents that are at risk for hypoglycemia and observe them for signs and symptoms of low blood glucose. If the blood glucose reading is 70 mg/dl or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with follow up blood glucoses as indicated, and notify the practitioner of the results as ordered. The blood sugar(s) and treatment will be documented as per facility protocol.

Review of the clinical record revealed Resident R3 was admitted to the facility on 6/21/25, with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and depression.

Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 12/4/25, indicated the diagnoses remain current.

Review of Resident R6 physician's order revealed the following orders:

- On 10/10/25, Humalog insulin (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours), inject as per sliding scale: if 0-70 = initiate hypoglycemic protocol.

Review of Resident R3's orders failed to indicate an ordered hypoglycemic protocol.

Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed the CBG's were as follows:

- On 12/11/25, at 7:50 a.m. the CBG was noted to be 69.

- On 12/15/25, at 8:36 a.m. the CBG was noted to be 61.

Review of Resident R3 eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician order was not followed for hypoglycemic protocol.

Review of Resident R3 care plan dated 6/21/25, revealed the following intervention: Monitor/document/report as needed any sign and symptoms of hypoglycemia.

Review of a clinical record indicated Resident R5 was admitted to the facility on 1/11/26, with diagnoses that included diabetes, high blood pressure, and history of falling.

Review of the MDS dated 1/17/26, indicated the diagnoses are current.

Review of Resident R5 physician's orders revealed the following orders:

- On 1/11/26, Oral hypoglycemic protocol: Blood glucose <45 mg/dl - give 30 g (grams) of carbohydrate (8 oz of juice/soda or 2 tbsp (tablespoon) jelly/sugar). Blood glucose 45-59 mg/dl - give 20 g of carbohydrate (6 0z of juice/soda or 1.5 tbsp jelly/sugar). Blood glucose 60 - 100 mg/dl - give 15 g of carbohydrate (4 oz of juice/soda or 1 tbsp jelly/sugar) as needed for hypoglycemia protocol. Repeat blood glucose level in 15 minutes.

- On 1/11/26, Glucagon emergency injection kit one milligram (mg) inject one mg intramuscularly as needed for hypoglycemia protocol. Give if blood glucose is less than 70 mg/dl and resident is unable to swallow/unconscious. Recheck blood glucose in 15 minutes. If still less than 70 mg/dl (after already given glucagon) CALL 911.

- On 1/11/26, Humalog insulin per sliding scale: if 0-70 = initiate hypoglycemic protocol.
Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed the CBG's were as follows:

- On 1/23/26, at 8:14 p.m. the CBG was noted to be 34.

- On 1/25/26, at 7:55 a.m. the CBG was noted to be 62.

- On 1/26/26, at 7:50 a.m. the CBG was notes to be 57.

- On 1/27/26, at 8:15 a.m. the CBG was noted to be 59.

- On 1/28/26, at 5:29 a.m. the CBG was noted to be 37.

- On 1/28/26, at 12:57 p.m. the CBG was noted to be 67.

- On 2/10/26, at 5:02 p.m. the CBG was noted to be 66.

- On 2/11/26, at 12:54 p.m. the CBG was noted to be 53.

- On 2/11/26, at 9:29 p.m. the CBG was noted to be 68.

- On 2/16/26, at 1:03 p.m. the CBG was noted to be 67.

- On 2/17/26, at 1:23 p.m. the CBG was noted to be 49.

- On 2/18/26, at 4:29 p.m. the CBG was noted to be 53.

- On 2/21/26, at 8:04 a.m. the CBG was noted to be 66.

Review of the eMAR progress notes revealed:

- On 1/23/26, at 8:14 p.m. Resident R5 received a glucagon injection. On 1/23/26, at 9:38 p.m. the CBG was 168. Resident was not assessed for hypoglycemia, and the physician was not notified of abnormal results.

- On 1/28/26, at 5:29 a.m. Resident R5 received a glucagon injection. On 1/28/26, at 5:42 a.m. the CBG was 168. Resident was not assessed for hypoglycemia, and the physician was not notified of abnormal results. No documentation noted for 1/28/26, CBG of 67.

Review of Resident R5's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates.

Review of Resident R5 care plan dated 1/12/26, revealed the following intervention: Staff will evaluate resident for signs and symptoms of hypoglycemia.

During an interview on 2/25/26, at 2:00 p.m. Licensed Practical Nurse (LPN) Employee E1 stated for diabetic residents with blood sugars under 90 they give the resident juice and recheck the blood glucose in 15 minutes; if the blood glucose was elevated it would depend on the resident's baseline to what number would concern them. If it was elevated over the resident's baseline they would call the physician to get new orders. When asked if they would document, LPN Employee E1 stated they would document in the progress note.

During an interview on 2/25/26, at 2:02 p.m. Registered Nurse (RN) Employee E2 stated any blood glucose under 80 they would consider hypoglycemia and would get the resident a snack, juice, or glucagon. They stated blood glucose over 120 they would review the orders for a sliding scale and follow that. They would call the physician if the resident had signs or symptoms, and depended on the resident's baseline. When asked if they would document, RN Employee E2 stated they would document in the progress notes if the blood glucose was "super high", they defined "super high" as any number over the parameter and if the resident was having signs or symptoms.

During an interview on 2/25/26, at 2:06 p.m. LPN Employee E3 stated it depends on the order if they call the physician, and it depends on the resident's baseline. They stated they would review the blood glucoses to determine what "baseline" was. They would follow the physician's orders. If the blood glucose was less than 70 they would give the resident a snack. When asked if they would document, LPN Employee E3 stated they would document everything they did, the resident's signs and symptoms, and the physicians response to their telephone call.

During an interview on 2/25/26, at 2:10 p.m. LPN Employee E4 stated for blood glucoses under 90 they would monitor the resident closely for signs and symptoms their glucose level was dropping. For blood glucose levels of 70 - 80, they would give the resident a snack or juice. For elevated blood glucose it would depend on the resident's baseline. For blood glucose over 150 they would monitor the resident and call the physician over 200. They stated they would document in the progress notes and on the shift report for the next shift.
During an interview on 2/26/26, at 8:30 a.m. the Medical Director stated he would definitely expect a telephone call for blood glucose results in the 30's. He stated that a lot of the staff notify him via their cell phones. He confirmed the nursing staff needed to document better to take credit for their actions. He confirmed Resident R3 and R5 have not been sent out to the hospital from the facility for hypoglycemia.

During an interview on 2/26/26, at 8:45 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physician's orders for Residents R3 and R5.

28 Pa. Code 201.18 (b)(1) Management

28 Pa. Code 201.29(d) Resident Rights

28 Pa. Code 211.10 (c)(d) Resident Care policies

28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 03/10/2026

1. R3 and R5 physician orders are being implemented and changes in conditions are being communicated to the physician.

2. Current patients have the potential to be affected. The facility completed an initial audit on current patients in house on February 25, 2026. The audit reviewed blood glucose checks from February 1 through February 25, 2026. The audit revealed one additional patient was affected. The patient's physician was notified of the blood glucose level.

3. The director of nursing established a blood glucose protocol with the medical director. The director of nursing and/or designee educated the nurses responsible for administering medications on this protocol. The education included blood glucose parameters, physician communication and documentation requirements. The facility has created blood sugar thresholds on current diabetic residents which trigger if blood sugars are below or above the protocol parameters. Failure to comply with the protocol will result in progressive discipline.

4. The director of nursing and/or designee will audit blood glucose results twice a week for one month and then weekly for a month and then randomly thereafter to validate the blood glucose protocol is implemented. Results of this audit will be communicated at the monthly Quality Assessment and Assurance Committee meetings

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) REQUIREMENT Discharge Process:

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.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:

Based on a review of facility policy and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for eleven of eleven months (February 2025 through January 2026).

Findings include:

Review of the facility policy "Transfer and Discharge (including AMA)" dated 1/15/26 with a prior review date of 1/16/25, indicated "The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manor in which they can understand." The facility will maintain evidence that the notice was sent to the Ombudsman."

Federal Regulations further define emergency transfers as, "When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer."

A request to review facility documents on 2/24/26, of the facility's compliance in notifying the State Ombudsman Office revealed the facility failed to provide documented evidence of notifying the State Ombudsman Office of resident transfers and discharges for the time frame of 1/2025 through 1/2026.

During an interview on 2/26/25, at 9:30 a.m., the Nursing Home Administrator confirmed the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division during the past twelve months.

28 Pa. Code 201.18(b)(3)(e)(2) Management.

Plan of Correction - To be completed: 03/10/2026

1. Facility is now reporting resident transfers to the State Ombudsman Office.

2. Current patients who are transferred out of the facility have the potential to be affected. Facility completed an audit for February 2026 and determined residents transferred out of the facility had documentation in place informing the State Ombudsman Office of the transfers.

3. The Nursing Home Administrator educated Social Services on the Federal Regulation 628 and the facility Transfer and Discharge Policy which included failure to implement the policy and regulation would result in progressive disciplinary action.

4. The Nursing Home Administrator will audit the communication to the State Ombudsman Office on a monthly basis. Results of this audit will be communicated at the monthly Quality Assessment and Assurance Committee meetings.

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