Cedarwood Rehab: Wound Care Order Ignored 11 Days - PA
The resident, identified in inspection records only as Resident 1, had an open wound on her right hip severe enough to reach through skin and underlying tissue, the kind of injury classified at the highest level of pressure ulcer severity. She was cognitively intact, according to a February assessment, meaning she understood what was happening to her body. Her wound vac, a device that uses continuous suction to pull fluid from a wound, reduce bacteria, and draw the edges of damaged tissue together, had been running at the lower setting the entire time.
Federal inspectors visited Cedarwood Rehabilitation and Healthcare Center on March 31, 2026, responding to a complaint. What they found was straightforward: a specialist had seen the wound, made a recommendation, and the facility had not acted on it.
The Director of Nursing, interviewed that afternoon at 12:25 p.m., confirmed it. The wound care clinic's recommendations from March 20 had not been entered into Resident 1's clinical record. Not delayed by a day or two. Not pending a physician callback. Simply not done, as of the last day of the inspection.
A stage 4 pressure ulcer is not a minor condition. It is an open wound that has destroyed skin and reached into the muscle or bone beneath it. The wound vac in place since at least March 10 was designed to accelerate that healing, with physician's orders specifying the foam dressing, the airtight seal, the suction level, and the schedule: changes every Monday, Wednesday, and Friday. The consultant who examined the wound ten days later concluded the suction needed to be stronger. That judgment went nowhere.
The gap between the consultant's visit and the inspection was eleven days. During that time, Resident 1's treatment records showed no update to the suction setting.
Pennsylvania's nursing standards, cited in the inspection, require registered nurses to collect ongoing data about a resident's condition, compare it against clinical norms, and carry out care actions that promote healing. The inspection found that process broke down at the point where a specialist's written recommendation should have been reviewed with the attending physician and translated into an updated order.
It did not happen. The Director of Nursing did not dispute that.
Inspectors classified the violation as causing minimal harm or the potential for actual harm, the lower end of the federal severity scale. The finding applied to one of five residents whose records were reviewed during the complaint inspection.
What the records do not show is how Resident 1's wound responded during those eleven days. A wound vac running at insufficient suction is still a wound vac, still removing some fluid, still applying some pressure. Whether the difference between 120 and 150 millimeters of mercury mattered to the condition of her right hip during that stretch is not something the inspection report addresses. The consultant believed the change was necessary. The facility never made it.
Cedarwood Rehabilitation and Healthcare Center is a nursing and rehabilitation facility in Tyrone, a small city in Blair County in central Pennsylvania.
The inspection record closes with the Director of Nursing's confirmation and no indication that the order had been entered by the time inspectors left the building. Resident 1's wound vac was still running at the setting a specialist had said, eleven days earlier, was not enough.
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: August 5, 2026 · Our methodology
CEDARWOOD REHABILITATION & HEALTHCARE CENTER in TYRONE, PA was cited for violations during a health inspection on March 31, 2026.
She was cognitively intact, according to a February assessment, meaning she understood what was happening to her body.
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.