Health inspection·May 15, 2025

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that a dental appointment was scheduled for one of eight residents reviewed (Resident 6). Residents Affected - Few Findings include: A facility policy for dental care, dated January 30, 2025, revealed that the facility is to provide routine and emergency dental care for residents including follow-up dental appointments. A quarterly MDS assessment for Resident 6, dated May 5, 2025, revealed that the resident was cognitively intact, required staff supervision with care, and had her own natural teeth. A physician's order for Resident 6, dated October 10, 2024, revealed that the resident was to see the oral surgeon for tooth extraction. An interview with Resident 6 on May 15, 2025, at 11:44 a.m. revealed that she has an extremely sensitive tooth on her right side, and she believed that she was to have a tooth pulled and has not had it pulled. As of May 15, 2025, there was no documented evidence that Resident 6 saw the oral surgeon to have her tooth pulled. An interview with the Director of Nursing on May 15, 2025, at 11:52 a.m. confirmed that the appointment to have her tooth pulled with the oral surgeon was never made and should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 28 Pa. Code 211.15(a) Dental Services. Page 1 of 3 395393 395393 05/15/2025 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of eight residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated April 18, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included diabetes. A dental summary note, dated August 2, 2024, revealed that Resident 1 was present for the insertion of lower complete denture. Denture care and wearing instructions were given to the resident. Observations and interview with Resident 1 on May 15, 2025, revealed that he had no natural teeth and was not wearing any dentures. He said he did not have any dentures right now, because they broke. He said he wanted dentures because some of the foods are difficult to chew. Review of nurse aide task documents for February, March, April and May 2025 revealed that the resident was to have denture care during the day shift and the evening shift. Not applicable/refused was documented on the day shift on April 1 and on the evening shift on February 2, 25, 26; March 6, 11, 12, 13, 19, 27; April 2, 9, 10, 13, 15, 17, 22, 30; and May 1, 8, and 14, 2025. All other entries were documented as Y (yes). Interview with Nurse Aide 1 on May 15, 2025, at 3:08 p.m. indicated that Resident 1 did not have the dentures in his mouth or did not have them to provide denture care. She explained that she was documenting refused, but she changed to not applicable because he did not refuse, there were no dentures. Interview with the Director of Nursing on May 15, 2025, at 3:29 p.m. confirmed that nurse aide documentation of Resident 1's denture care was not accurately documented because the resident's dentures were lost. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services. 395393 Page 2 of 3 395393 05/15/2025 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition in the residents' rooms. Residents Affected - Many Findings include: Manufacturer's instructions for the Packaged Terminal Air Conditioner (PTAC - a heating and cooling system designed to be mounted through a wall to control room temperature) indicated that the air filters are to be cleaned every two weeks, or more often if necessary. Observations in resident room [ROOM NUMBER], on May 15, 2025, at 10:22 a.m. revealed that the room had a PTAC unit. The Maintenance Director was able to remove the filter from the unit and it was covered with a gray-brown layer of removable debris. Observations in resident room [ROOM NUMBER] on May 15, 2025, at 11:51 a.m. revealed that the room had a PTAC unit. The Maintenance Director was able to remove the filter from the unit and it was covered with a thick, gray-brown layer of removable debris. Interview with the Maintenance Director at May 15, 2025, at 10:22 a.m confirmed that the PTAC filters needed cleaned. Each resident room has it own PTAC unit and he believed their filters should be cleaned twice a year, approximately every six months. He started employment with the facility in January 2025 and has not cleaned any filters as part of routine maintenance. He thought they were cleaned in October or November of 2024. 28 Pa. Code 201.18(b)(3) Administrator's Responsibility. 395393 Page 3 of 3