Cedarwood Rehabilitation & Healthcare Center
CEDARWOOD REHABILITATION & HEALTHCARE CENTER in TYRONE, PA — inspection on March 31, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
that Resident 4 fell. He was in a wheeled desk chair by the housekeeping closet. We transferred him
children, and lots of people going back and forth. It seemed to make all the residents more anxious
the heat being on.
All the residents have an increase in confusion, irritability, agitation, and wandering when it feels hot and stuffy. Resident 4 did not want to go to bed after lunch as he seemed mesmerized with watching all the children and visitors coming and going.
However, Licensed Practical Nurse 7 also recalled that she was not on the floor at the time of the incident because she was on break.
When she returned to the floor Registered Nurse 4 was assessing Resident 4. A witness statement from Nurse Aide 3 dated March 21, 2026, revealed that she was working on the third floor when a dietary worker told her that a resident was on the floor.
Nurse Aide 3 went upstairs, and two dietary workers already had him up off the floor, and on a rolling computer chair in the hallway.
Nurse Aide 3 called the Registered Nurse that was working and went to find the Nurse Aides who were on the fourth floor. An orthopedic consultation dated March 31, 2026, at 11:00 a.m. revealed that Resident 4 had a left proximal humerus fracture after a fall on cement. Resident 4 would need a computed tomography (ct scan- noninvasive imaging) for surgical planning and needed to have a family member attend the next appointment to have surgical discussions or conservative care.
The facility's investigation revealed no documented evidence that a thorough investigation was conducted, as there was no documented evidence that the investigation included witness statements from the dietary aides that assisted the resident after the fall on March 21, 2026.
Interview with Director of Nursing on March 31, 2026, at 3:43 p.m. confirmed that she did not obtain witness statements from dietary staff because she did not believe they would have done that.
She also indicated that she did not investigate the lack of RN assessment prior to the resident being moved to a rolling desk chair.
Interview with Nursing Home Administrator on March 31, 2026, at 3:53 p.m. confirmed that all facility staff were trained upon hire to report to a nurse if a resident had a change in condition. 28 Pa.
Code 201.14(a) Responsibility of licensee. 28 Pa.
Code 201.18(b)(1) Management. 28 Pa.
Code 201.18(e)(1) Management. 28 Pa.
Code 211.12(d)(1)(5) Nursing Services.
395393 03/31/2026
Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686
physician for one of 5 residents reviewed (Resident 1).Findings include: The Pennsylvania Code, Title
the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.An annual Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 24, 2026, indicated that the resident w as cognitively intact, had a stage 4 pressure ulcer (a localized injury to the skin and underlying tissues, caused by prolonged pressure)Physician's orders for Resident 1 dated March 10, 2026 included an order for the right hip wound and surrounding tissue to be cleaned with soap and warm water, rinsed with saline, and a wound vac applied (a medical device that applies gentle continuous suction to a wound to accelerate healing using a special foam dressing, an airtight seal and a vacuum pump to remove fluids, reduce bacteria, increase blood flow, and draw wound edges together) making sure to place some of the black foam into the tunneling, change every Monday, Wednesday and Friday and continue suction at 120 mmHg.A wound consultant note for Resident 1, dated March 20, 2026, revealed that the resident had a stage 4 pressure ulcer to her right hip and required her wound vac suction to be changed from 120 mmHg to 150mmHg.A review of Resident 1's Treatment Administration Record (TAR), dated March 2026, revealed that as of March 31, 2026, the resident's recommended change in wound vac suction to her right hip had not been initiated.
Interview with the Director of Nursing on March 31, 2026, at 12:25 p.m. confirmed that wound care recommendations made by the wound care clinic on March 20, 2026, were not updated in her clinical record as of March 31, 2026.28 Pa.
Code 211.12(d)(1)(3)(5) Nursing Services.