Cedarwood Rehab: Safety Oversight Failures - PA
That's what federal inspectors found at Cedarwood Rehabilitation & Healthcare Center during a January 2025 survey. The facility's Quality Assurance and Performance Improvement committee, the internal body charged with tracking compliance and driving corrections, had failed to successfully carry out its own plan for keeping the facility in line with safety regulations.
The failure wasn't a surprise violation. It was a repeat one.
Inspectors had cited Cedarwood during a previous survey ending December 11, 2024, for failing to provide menus made in advance and followed. That's a basic requirement — residents in a nursing home are entitled to know what they'll be eating and to receive what they were promised. The facility's response at the time was to develop a plan of correction. That plan included completing audits and reporting the results back to the QAPI committee for review.
The January 2025 inspection found that the plan hadn't worked.
What inspectors documented under F689 was a finding of potential for actual harm. That tag covers accident hazards and the facility's responsibility to identify and remove them. Applied here, it reflects a judgment that the failure wasn't just administrative, a missed form or a late menu posting. It represented a breakdown in the system that exists specifically to catch and correct those failures before residents are hurt.
The QAPI process is supposed to be the backstop. When a deficiency is cited, the facility develops a correction plan. That plan goes to the committee. The committee tracks whether it's working. If the audits were completed and reported as the plan required, the committee reviewed them and still didn't catch that the underlying problem persisted. If the audits weren't completed at all, the committee failed to notice that either.
The inspection report doesn't specify which. It says the committee failed to successfully implement the plan. The result was the same: a violation cited in December came back in January.
Cedarwood serves residents in Blair County, a part of central Pennsylvania where nursing home options are limited and families often have few alternatives when a loved one needs skilled rehabilitation or long-term care. Residents in facilities like Cedarwood depend on the internal oversight structure to catch problems that families and the residents themselves may never see. A QAPI committee that isn't functioning means the facility's self-correction mechanism isn't functioning.
The menu violation that triggered all of this may seem minor in isolation. A missed menu, a meal that didn't match what was posted. But the specificity of the requirement exists for a reason. Residents with dietary restrictions, allergies, religious observances, or simply strong preferences about food, one of the last areas of daily life where a nursing home resident exercises any real control, rely on accurate menus. When the menu says chicken and dinner is something else, a resident with a swallowing disorder may face a real risk. A resident managing diabetes needs to anticipate carbohydrates. The menu is a care document, not a courtesy.
The facility acknowledged as much when it wrote its correction plan after December's survey. It said audits would be completed. It said results would go to the committee. Those commitments didn't hold.
Inspectors noted that few residents were affected by the violations documented in the January survey. That's a narrow finding, not a clean one. It means the harm was limited in scope at the time inspectors were present. It doesn't mean the oversight failure was limited.
A quality assurance committee that cannot implement its own correction plans is a committee that cannot be relied upon to catch the next problem, whatever it turns out to be.
At Cedarwood in January 2025, the audits were supposed to have been done. The committee was supposed to have reviewed them. The menu was supposed to have been followed. Inspectors came back and found that the system built to ensure all of that had not done its job.
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.
That's what federal inspectors found at Cedarwood Rehabilitation & Healthcare Center during a January 2025 survey.
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.