Cedar Crest Post Acute

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that physician prescribed medications were administered as ordered to one of four sampled residents. (Resident CR 1) Findings include:Resident CR 1 was admitted to the facility with diagnoses that included end stage kidney disease and emphysema. Facility provided documentation revealed that on April 16, 2026, the resident was administered medications to treat hypertension (metoprolol and amlodipine), a medication to treat attention deficit disorder (Ritalin), a medication to prevent blood clots (Eliquis), and a medication to reduce stomach acid (Protonix). Review of the resident's physician orders for April 2026 revealed that the medications were not ordered for Resident CR 1.In an interview on April 30, 2026, at 10:30 a.m., the Director of Nursing confirmed that Resident CR 1 was administered medications not prescribed by the physician. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 32 sampled residents. (Residents 65 and 170)Findings include: Review of the facility policy entitled, Administering Medications, last reviewed April 30, 2025, revealed that a resident may only self-administer their own medications if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the facility policy entitled, Self-Administration of Medications, last reviewed April 30, 2025, revealed that as part of the evaluation, the interdisciplinary team assessed each resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate for the resident, if it was deemed safe and appropriate for a resident to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from potential chemical restraints for one of five sampled residents who were ordered psychotropic medications. (Resident 93) Findings include: Clinical record review revealed that Resident 93 had a diagnoses that included anxiety and psychotic disorder with hallucinations. On August 27, 2025, a physician ordered staff to administer an anti-anxiety medication, (lorazepam), every 24 hours as needed for anxiety and sleep. There was no date in the order that indicated when staff were to stop administering the as needed medication. Review of Resident 93's Medication Administration Record revealed staff had administered the lorazepam two times in October 2025, and three times in November 2025. On October 14, 2025, a physician ordered staff to administer an anti-anxiety medication (lorazepam), every 24 hours as needed for anxiety and agitation, in addition to the August 27, 2025 as needed anti-anxiety medication order. There was no date in the order that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observation and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's status for one of 32 sampled residents. (Resident 11)Findings include: Clinical record review revealed that Resident 11 had diagnoses that included stroke, nontraumatic intracerebral hemorrhage (bleeding inside the brain), unspecified sequelae of other cerebrovascular disease (long-term effects of unknown brain blood vessel problem), coronary artery disease, heart failure, hypertension, occlusion and stenosis of bilateral carotid arteries, atrial fibrillation, type two diabetes mellitus and long-term use of insulin. The MDS assessment dated September, 19, 2025, incorrectly indicated in Section N (Medications) that the resident did not receive insulin injections or an anticoagulant or antiplatelet during the previous seven days. Review of the 2025 Medication Administration Record for September revealed that staff administered an anticoagulant, antiplatelet, and an insulin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of clinical records and staff interview, it was determined that the facility failed to implement physicians' orders for one of 32 sampled residents. (Resident 151)Findings include: Clinical record review revealed that Resident 151 had diagnoses that included hypertension (high blood pressure) and chronic systolic (congestive) heart failure. On November 3, 2024, the physician ordered that staff administer blood pressure medication (metoprolol) one time a day. The physician ordered that staff not administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mm/Hg) or if the resident's pulse was less than 60 beats per minute. Review of Resident 151's Medication Administration Records (MAR) for August, September, October, and November of 2025, revealed that staff failed to record the resident's blood pressure or pulse prior to the administration of the medication 10 times in August, seven times in September, and four…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to provide sufficient enteral nutrition (delivery of nutrition by a feeding tube) to maintain proper hydration and health in accordance with the physician's order for one of four sampled residents receiving nutrition by a feeding tube. (Resident 100) Findings include: Review of the facility policy entitled, Enteral Nutrition, last reviewed on April 30, 2025, revealed that a dietician monitored residents who were receiving enteral nutrition, made appropriate recommendations for interventions to enhance tolerance and nutritional adequacy, that nursing staff and providers monitored the resident for signs and symptoms of altered electrolytes, and that nursing was to confirm the orders for enteral nutrition were complete including instructions for flushing. Clinical record review revealed that Resident 100 had diagnoses that included history of a brain injury, difficulty swallowing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) for one of two nursing units observed during medication administration. (Second floor)Findings include: Observation of medication administration on November 25, 2025, from 8:05 a.m. to 9:00 a.m., revealed 38 medication opportunities with two medication errors that resulted in a medication administration error rate of 5.26%. Clinical record review revealed that Resident 152 had diagnoses that included asthma, chronic obstructive pulmonary disease (COPD), and corona virus 2019. A review of the physician's order dated November 20, 2025, revealed that staff was to administer three milliliters (ml) of ipratropium-albuterol inhalation solution 0.5-2.5 (3) milligram (mg)/3ml (a medication used to treat symptoms of COPD) inhaled every 12 hours and to be given prior to administering Advair Diskus Aerosol Powder 500-50 micrograms (a medication used to treat symptoms of COPD). Observation of the medication pass on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation it was determined that the facility failed to store food in a sanitary manner on one of three nursing units. (MedBridge)Findings include:Observation in the MedBridge resident refrigerator on November 25, 2025, at 9:34 a.m., revealed that the top shelf had a thick layer of crumbs and dried liquid debris. On the middle shelf there was an area of a white sticky substance and part of a plastic bag was stuck to the shelf. The area along the length of the bottom of the refrigerator under the drawers had a thick layer of a dark sticky substance. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection on one of three nursing units. (MedBridge) Findings include: Review of the facility policy entitled, Isolation- Categories of Transmission-Based Precautions, last reviewed April 30, 2025, revealed that transmission based precautions (TBPs) included contact precautions, droplet precautions, airborne precautions and required certain personal protective equipment (PPE). If a resident was identified as having a communicable disease, then TBPs were to be initiated. Staff were to post a sign on the residents' door and chart that alerted all personnel and visitors entering the room of the need for and the type of precaution. If a resident was on contact precautions, staff and visitors were expected to wear gloves and a disposable gown upon entering the room and remove before leaving the room. If a resident was on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement comprehensive care plan interventions to address individual resident needs as identified in the comprehensive assessment for one of seven sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included chronic obstructive pulmonary disease, osteoarthritis, and osteoporosis. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was able to communicate her needs clearly and required staff assistance for mobility. Review of the current care plan revealed that Resident 1 was at risk for falls with an intervention for staff to ensure that the resident had a reacher (an assistive tool to help retrieve objects) placed within her reach. In an interview at 1:30 p.m., on September 4, 2025, Resident 1 stated, I haven't had my reacher in a while. I would like to have it. Observation of Resident 1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident interview, it was determined that the facility failed to accomodate the needs and maintain dignity for two of seven sampled residents. (Residents 1 and 3) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included a stroke with hemiplegia on her right dominant side, aphasia (inability to swallow), dysphagia (speech impairment), and depression. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident needed help with self care, had limitations in range of motion on one side of her upper extremities, and required maximum assistance with toileting and dressing. Further review of the MDS assessment revealed that family had relayed to the facility that it was very important for the resident to choose her own activities, clothing, and bed time. A review of the care plan revealed that the resident had a communication deficit and there was an intervention for staff to anticipate and meet her needs. In…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for one of 30 sampled residents. (Resident 194) Clinical record review revealed that Resident 194 was admitted to the facility on [DATE], and had diagnoses that included retention of urine, Parkinson's disease, and dementia. The Minimum Data Set Care Area Assessment summary dated September 3, 2024, noted that the resident's urinary incontinence and cognitive decline/dementia were to be addressed in the care plan. There was no evidence that interventions to address Resident 194's urinary incontinence and cognitive decline/dementia were addressed in the current care plan. In an interview on October 9, 2024, at 2:40 p.m., the Director of Nursing confirmed there was no documented evidence that the identified care areas were addressed in Resident 194's current care plan and they should have been. 28 Pa. Code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of 30 sampled residents. (Residents 30, 202) Findings include: Clinical record review revealed that Resident 30 was admitted [DATE], with diagnoses that included diabetes (insufficient production of insulin, causing high blood sugar). A physician's order, dated, May 3, 2023, directed staff to take a finger stick measurement of the resident's blood sugar before each meal at 6:30 a.m., 11:30 a.m., and 4:30 p.m. Review of Resident 30's Medication Administration Record (MAR) revealed that on August 27, 2023, at 6:30 a.m., October 19, 2023, at 6:30 a.m., and October 25, 2023, at 11:30 a.m., there was a lack of documentation to support that staff took a measurement of the resident's blood sugar. A physician's order, dated July 13, 2023, directed staff to take Resident 30's weight every week on Thursday. Review of the record and the MAR for August, September, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.