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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CEDARWOOD REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

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

Initial comments:
Based on an incident survey completed on March 25, 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:

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

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.

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on review of facility policies, residents' clinical records, and the facility's investigative documents, as well as resident and staff interviews, it was determined that the facility failed to ensure that a professional (licensed) nurse completed a timely assessment when changes in condition occurred for one of five residents reviewed (Resident 1). This deficiency was cited as past noncompliance.

Findings include:

The facility's policy regarding change in condition, dated January 25, 2024, indicated that a nurse would make detailed observations and gather relevant and pertinent information for the provider when a change in condition has occurred.

The facility's investigation, dated March 8, 2024, indicated that Resident 1 rang for the nurse aide around 1:00 p.m. and asked to see the nurse because she was not feeling well. She told Nurse Aide 2 that she was having chest discomfort and that she felt like she was getting COVID or pneumonia again. Nurse Aide 2 went to Licensed Practical Nurse 1 and told him that Resident 1 was not feeling well, that she was having chest pain, and that she thought it was pneumonia again. At 2:00 p.m. Resident 1 rang her call bell and asked the nurse aide to get the nurse to see her because she was not feeling well. At 3:00 p.m she again rang her call bell and told Nurse Aide 2 that she still had not seen the nurse and that she would like some Tylenol for chest pain. Nurse Aide 2 informed Licensed Practical Nurse 1 that Resident 1 was still complaining of chest pain and that she would like some Tylenol. Nurse Aide 2 said that Licensed Practical Nurse 5 was standing outside of Resident 1's room at that time and she asked her to assess the resident; however, Licensed Practical Nurse 5 stated that she did not have keys to the medication cart and therefore could not assess the resident. The resident rang her call bell again at 5:00 p.m. and asked Nurse Aide 2 when was a nurse going to come and see her.

A written statement by Nurse Aide 4, dated March 8, 2024, indicated that on March 7, 2024, at approximately 1830 she ran into Nurse Aide 2 and was told by Nurse Aide 2 that she had approached Licensed Practical Nurse 1 several times to alert him that Resident 1 was having chest discomfort and wanted to be seen; however, he never went to see her. After Nurse Aide 4 got her work done she went to Registered Nurse 3 and informed her that Resident 1 was complaining of chest pain and that Licensed Practical Nurse 1 failed to assess her or notify the registered nurse that she was having chest pain.

Resident 1 was assessed by the registered nurse and was sent to the hospital for further evaluation and admitted.

Interview with the Director of Nursing and Assistant Director of Nursing on March 25, 2024, at 12:08 p.m. confirmed that Licensed Practical Nurse 1 should have assessed Resident 1 within his scope of practice and then called for the registered nurse if the resident needed further assessment.

Following the incident on March 7, 2024, the facility's corrective actions included:

The Director of Nursing immediately interviewed all interviewable residents to determine if their complaints have been reported to the nurse and that the nurse assessed the resident.

The licensed practical nurse was suspended and then terminated.

On March 8, 2024, the staff were educated regarding their roles as a mandated reporter regardless of chain of command or fear of retaliation, abuse, and documentation was to occur at the time of the event.

The Director of Nursing initiated audits on March 8 daily for five days and then weekly for four weeks to determine if resident complaints have been assessed for the need for further assessment or care. Further audits will be completed as determined by the Quality Assurance Performance Improvement (QAPI) committee.

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

Plan of Correction - To be completed: 04/23/2024

Past noncompliance: no plan of correction required.

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