Cedarwood Rehab: Care Plan Oversight Failures - PA
Cedarwood Rehabilitation & Healthcare Center was cited in January 2025 for failing to keep residents' care plans properly updated, a violation that touches nearly every aspect of how a nursing home manages the health and daily needs of the people living there. A care plan is the document that drives decisions about a resident's medications, therapies, diet, and personal needs. When it goes stale or incomplete, the people responsible for a resident's care are working from outdated information.
What made the January citation different from a routine deficiency was what came before it.
During a survey that ended September 17, 2024, Cedarwood had already been cited for failing to meet professional standards, a related deficiency. The facility responded with a plan of correction, a formal written commitment submitted to regulators that described exactly how it intended to fix the problem. According to that plan, Cedarwood would conduct audits and report the results to its Quality Assurance and Performance Improvement committee, known as QAPI, for ongoing review. The QAPI committee is the internal body charged with catching problems before they reach residents, the facility's own mechanism for self-correction.
The audits were supposed to happen. The results were supposed to go to the committee. The committee was supposed to act on them.
None of it worked.
When inspectors returned in January 2025, they found that the QAPI committee had failed to successfully implement the plan. Care plans were still not being updated the way they should be. The facility had told regulators it had a system in place to catch exactly this kind of failure, and that system had not caught it.
This is the specific shape of the violation: not a facility that ignored the problem from the start, but one that wrote down a detailed promise, submitted it to the government, and then did not follow through on it. The audits that were supposed to generate accountability produced no visible change in practice.
Care plan violations can seem bureaucratic from the outside. They involve paperwork, committee meetings, audit schedules. But the paperwork describes real people. A care plan records what a resident can and cannot do for themselves, what they are at risk for, what interventions are in place to protect them. A resident whose care plan has not been updated after a fall, a new diagnosis, or a change in their ability to swallow food safely is a resident whose care team may be operating without a current picture of who that person is and what they need.
Cedarwood has roughly four months between its September 2024 citation and its January 2025 inspection to demonstrate that its corrective plan was working. The inspection record indicates it could not.
The QAPI process is supposed to function as a nursing home's internal early warning system, the structure that catches drift before it becomes harm. At Cedarwood, that structure was described on paper in September and found to be ineffective in January. The gap between the written commitment and the actual performance was the finding.
Federal inspectors did not describe specific residents who were harmed as a result of the outdated care plans. What the record shows is a facility that identified a compliance problem, designed a process to fix it, reported that process to regulators as its solution, and then returned to the same cited condition before the next survey was complete.
The January 2025 inspection closed with the care plan deficiency on the record again, the same category of problem as before, now carrying the additional weight of a broken corrective promise behind it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedarwood Rehabilitation & Healthcare Center from 2025-01-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
CEDARWOOD REHABILITATION & HEALTHCARE CENTER in TYRONE, PA was cited for violations during a health inspection on January 10, 2025.
A care plan is the document that drives decisions about a resident's medications, therapies, diet, and personal needs.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.