Cedarwood Rehab: Fall Investigation Failures - PA
The fall happened on March 21, 2026. The unit was busy that afternoon. According to a witness statement from Licensed Practical Nurse 7, the floor had flooded with visitors and children after lunch, and the foot traffic was making residents more anxious than usual. The heat was on, the unit felt humid and stuffy, and the combination had pushed residents into a state of heightened confusion, irritability, and wandering. Resident 4 had refused to go to bed. He was transfixed watching the children and visitors come and go.
LPN 7 was on break when he fell. She returned to the floor to find Registered Nurse 4 already assessing him.
What happened in between is where the story gets murkier. A witness statement from Nurse Aide 3 described how a dietary worker came to the third floor to tell her a resident was down. By the time Nurse Aide 3 got upstairs, two dietary workers had already lifted Resident 4 off the floor and placed him in a rolling computer chair in the hallway. Nurse Aide 3 called the registered nurse on duty and went to find the nurse aides working the fourth floor.
Nobody had assessed him before he was moved.
By March 31, an orthopedic consultation confirmed what the fall had done: a left proximal humerus fracture, meaning the upper bone of his left arm had broken near the shoulder joint. The orthopedist noted the fracture occurred after a fall on cement. Resident 4 would need a CT scan for surgical planning. A family member would need to attend the next appointment to discuss whether surgery or conservative care made more sense.
The facility's own investigation turned up no documented evidence that anyone had asked the dietary workers what they saw, what they did, or what condition Resident 4 was in when they found him on the floor. Those workers had been first on the scene. They were the ones who moved him. Their account of what happened in those minutes, before any nurse arrived, was never recorded.
When inspectors interviewed the Director of Nursing on March 31 at 3:43 p.m., she confirmed it. She had not obtained witness statements from dietary staff. Her reason: she did not believe they would have done that. She also acknowledged she had not investigated why Resident 4 had been moved to a rolling desk chair before a registered nurse assessed him.
That last detail matters. Moving a resident after a fall before a clinical assessment carries real risk. A fracture can be worsened. A spinal injury can be missed. The standard practice, for exactly that reason, is to keep a fallen resident still until a nurse evaluates them. Here, two dietary workers, trained to report changes in condition to nursing staff but not trained to conduct post-fall assessments, made the call to lift him.
The Nursing Home Administrator, interviewed ten minutes after the Director of Nursing, confirmed that all staff are trained on hire to report to a nurse when a resident has a change in condition. That training, apparently, did not prevent what happened. And the investigation that followed did not examine why.
Inspectors cited the facility under four Pennsylvania Department of Health regulations covering licensee responsibility, management, and nursing services.
What the inspection report does not say is whether Resident 4 had surgery. It does not say whether his family was reached in time for the orthopedic follow-up. It does not say whether the dietary workers who found him on the floor, lifted him into a chair, and walked away without being interviewed have any idea their account was considered irrelevant.
He was sitting in a rolling desk chair in a hallway, his head and shoulder hurting, before anyone with a nursing license looked at him. The people who moved him were never asked what they saw.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedarwood Rehabilitation & Healthcare Center from 2026-03-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
CEDARWOOD REHABILITATION & HEALTHCARE CENTER in TYRONE, PA was cited for violations during a health inspection on March 31, 2026.
The fall happened on March 21, 2026.
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.