Health inspection·February 5, 2026

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for three of 46 residents reviewed (Residents 4, 9, 11, ). Findings Include:The facility's policy regarding the use of psychotropic medications, dated January 27, 2026, indicated that the staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 12, 2025, revealed that the resident was cognitively intact, received antipsychotic medications (a psychotropic medication), and had diagnoses that included depression and bipolar disorder (a chronic mental health disorder characterized by extreme shifts in mood, energy and activity levels).Physicians' orders for Resident 4, dated May 24, 2025, included an order for the resident to receive 25 milligrams (mg) of Seroquel (an antipsychotic medication used to treat bipolar disorder) at bedtime. Physician's orders for Resident 4, dated June 20, 2025, included an order for the resident to receive 50 mg of Seroquel at bedtime. Physician's orders for Resident 4, dated August 31, 2025, included an order for the resident to receive 100mg of Seroquel at bedtime.There was no documented evidence in Resident 4's clinical record that the resident or the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to increasing the dose of Seroquel.Interview with the Director of Nursing on February 4, 2026, at 3:36 p.m. confirmed that there was no documented evidence in Resident 4s clinical record that the resident or resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to increasing the dose of Seroquel.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated November 12, 2025, indicated that the resident was always understood, could always understand others, and was cognitively intact. A nursing note for Resident 9, dated August 5, 2025, revealed that the resident's antidepressant medication Cymbalta was to be increased from 30 milligrams to 60 milligrams daily and that the resident's representative was aware. There was no documented evidence that a written informed consent was given to representative regarding increase in psychotropic medication. Interview with Director of Nursing on February 4, 2026 at 03:34 p.m. stated that she could not find informed consent signed by resident representative for increase in Cymbalta dose from 30 milligrams to 60 milligrams on August 2, 2025, and confirmed that a signed informed consent should have been obtained. A quarterly MDS assessment for Resident 11 dated December 3, 2025, revealed that the resident was cognitively impaired, received antipsychotic medications and had diagnoses that included non-Alzheimer's Dementia.Physician's orders for Resident 11, dated August 26, 2025, included an order for the resident to receive 2.5mg Zyprexa (an antipsychotic Residents Affected - Few Page 1 of 15 395393 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication) at bedtime. Physician's order for Resident 11, dated August 26, 2025, included an order for the resident to receive 25mg Seroquel twice a day.There was no documented evidence in Resident 11's clinical record that the resident or the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to starting the medications.Interview with the Director of Nursing on February 3, 2026, at 2:25 p.m. confirmed that there was no documented evidence in Resident 11's clinical record that that resident or resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to starting Zyprexa or Seroquel. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights. 28 Pa. Code 201.29(a)(j) Resident Right 395393 Page 2 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident representative regarding a fall (change in condition) for one of 46 residents reviewed (Resident 29). Findings include: The facility's policy regarding notification, dated January 27, 2026, indicated that facility promptly notifies the resident, his or her attending physician, and the resident representative of change in the resident's medical/mental condition and/or status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated October 23, 2025, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 29 dated January 31, 2026, revealed that the resident slid out of her electric wheelchair and onto the floor. There was no documented evidence that daughter was notified after fall. A special notification banner in Resident 29's electronic health record indicated that her daughter was to be contacted at all times for any change related to the resident. Interview with Resident 29 on February 3, 2026, at 11:30 a.m., revealed that the resident was upset that her daughter was not notified of her fall. Interview with the Director of Nursing on February 3, 2026, at 1:18 p.m. confirmed that Resident 29's daughter was not notified after the resident's fall on January 31, 2026. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395393 Page 3 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment for one of 46 residents reviewed (Resident 43). Findings include: The facility's policy regarding homelike environment, dated January 27, 2026, indicated that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated December 26, 2025, indicated that the resident was cognitively intact, required minimal assistance for care needs, and had diagnoses that included Alzheimer's and colon cancer. Observations of Resident 43's room on February 2, 2026, at 11:10 a.m., revealed that there were multiple quarter-sized to half-dollar-sized areas of chipped and peeling paint on the two walls around the resident's bed. Interview with the Maintenance Director on February 4, 2026, at 10:55 a.m., confirmed that the walls in room [ROOM NUMBER] were in need of repair to ensure a homelike environment for Resident 43. 28 Pa. Code 207.2(a) Administrator's Responsibility. 395393 Page 4 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for four of 32 residents reviewed (Residents 6, 39, 43, 97). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.An admission MDS assessment for Resident 6 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on December 27, 2025, which was 2 days after admission.An annual MDS assessment for Resident 39 revealed that the resident's annual MDS assessment was due to be completed by December 11, 2025, however, it was dated as completed on December 27, 2025, which was 16 days late.An admission MDS assessment for Resident 43 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on January 2, 2026, which was 15 days after admission.An annual MDS assessment for Resident 97 revealed that the resident's annual MDS assessment was due to be completed by November 22, 2025, however, it was dated as completed on December 7, 2025, which was 16 days late.Interview with the Director of Nursing on February 5, 2026 at 2:35 p.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records. 395393 Page 5 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of the residents. Findings include:Review of the activity calendar for the month of February 2026 revealed that there is one activity scheduled for a Sunday evening and it is for the super bowl. There were no other organized weekend activities. There were also no organized activities on the calendar after 2:00 p.m. for any unit other than the dementia unit. At 4:00 p.m. there is an activity on the dementia unit called tray pass. There were no other organized activities for the other units on the calendar after 2:00 p.m.Interview with a group of residents on February 2, 2026 at 1:30 p.m. revealed that they would like to have organized activities on the weekends and in the evenings. They stated that the organized activities end at 2:00 p.m. everyday and that there are no organized activities on the weekends. They stated that they have asked for weekend activities, but have been told that there is not enough interest to do them. Interview with the Activity Director on February 3, 2026 at 2:38 p.m. revealed that there are activity staff present on Saturday and Sunday for four hours, however, they do not hold organized activities. She stated that there had been no interest in the past and she didn't believe very many residents would participate. She stated she was aware that the residents would like organized activities on the weekends. She stated that there is an activity aide present in the facility until around 8:00 p.m. most nights, however, he focuses his time on the dementia unit from 4:00 p.m. on because they identified there were increased falls and he was to provide distraction activities. She stated that since he is on the dementia unit there would be no one else to hold evening activities for the other residents.28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Residents Affected - Some 395393 Page 6 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the environment remained as free of accident hazards as possible for two of 46 residents reviewed (Residents 88, 114). Findings include:The facility's policy regarding falls, dated January 27, 2026, revealed that resident's identified as fall risks will have interventions in place to prevent further falls.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated January 21, 2026, indicated that the resident was cognitively intact and required assistance for daily care. Resident 88's care plan, dated December 14, 2025 indicated that the resident was at risk for falls. Fall interventions included keeping her personal belongings within reach, and that she would have a reacher tool (used to grab objects that are beyond your reach).Observations of Resident 88 on February 5, 2026 at 10:30 a.m. revealed that she was sitting in her wheelchair beside her bed coloring on her over bed table. Her crayons were on her bed within reach, however, her other coloring books and colored pencils were further down her bed and not within her reach. Her reacher tool was on the other side of the bed on her nightstand. Interview with Resident 88 on February 5, 2026 at 10:30 a.m. revealed that she would use her reacher tool if she could reach it. Interview with Licensed Practical Nurse 1 on February 5, 2026 at 10:35 a.m. confirmed that Resident 88's reacher tool was out of her reach and that it should have been closer to her. Interview with the Director of Nursing on February 5, 2026 at 11:52 a.m. confirmed that Resident 88's reacher tool should have been in her reach.admission diagnosis for Resident 114 revealed that she has a fracture of the femur, difficulty in walking, and generalized muscle weakness.Observations of Resident 114 on February 3, 2026, 12:04 p.m. revealed that the resident was transported in his chair by Nurse Aide 2 from her bedroom towards the dining room for lunch with no leg rests on her chair. An interview with Nurse Aide 2 at that time confirmed that she did not apply leg rests to Resident 114's chair prior to transporting the resident because they were in the therapy department and she should have. An interview with the Director of Nursing on February 4 at 12:21 p.m. confirmed that leg rests should have been used as ordered when transporting Resident 114.28 Pa. Code 211.12(d)(5) Nursing Services. 395393 Page 7 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to provide pain management for two of 46 residents reviewed (Resident 7 & 48).Findings include:The facility's policy regarding pain management, dated January 27, 2026, indicated that the physician would order appropriate medication interventions to address the resident's pain. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 26, 2025, revealed that the resident was cognitively intact, was usually understood, and could usually understand, required assistance from staff for daily care needs, and received scheduled pain medication. The current care plan for pain indicated that Resident 7 had chronic back pain and medications were to be administered as ordered.Physician orders for Resident 7 dated December 24, 2025, included an order for her to receive one Lidocaine 4% patch (an over-the-counter medication patch used for the temporary relief of minor aches and pains) topically once a day in the morning for back and neck pain.Nursing administration notes for Resident 7, dated January 5, 2026, at 8:32 a.m.; January 6, 2026, at 8:02 a.m.; January 7, 2026, at 7:07 a.m.; and January 8, 2026, at 7:04 a.m indicated that the Lidocaine 4% External Patch was unavailable.An admission MDS assessment for Resident 48, dated November 1, 2025, revealed that the resident was cognitively intact, was understood, and could understand, required assistance from staff for daily care needs, and received scheduled pain medication. A care plan dated November 1, 2025, indicated that Resident 48 had pain to both knees and her right shoulder and medications were to be administered as ordered.Interview and observations of Resident 48 on February 2, 2026, at 1:57 p.m. revealed that the facility ran out of Lidocaine patches multiple times, and she has chronic pain. Physician orders for Resident 48 dated November 1, 2025, included an order for her to receive one Lidocaine 4% patch topically once a day in the morning to be applied to bilateral knees and the right shoulder. Nursing staff were to cut a patch into three strips.A nursing administration notes for Resident 48, dated December 29, 2025, at 7:18 a.m.; January 6, 2026, at 7:11 a.m.; and January 7, 2026, at 6:59 a.m. indicated that the Lidocaine 4% External Patch was unavailable.Interview with the Director of Nursing on February 4, 2026, at 3:32 p.m. confirmed that Lidocaine 4% patches were not administered as ordered to relieve pain for Residents 7 and 48, because the facility ran out, and the staff did not notify her, or the medical director. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. Residents Affected - Some 395393 Page 8 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to properly date medications after they were opened in one of three medication carts reviewed (second floor cart), failed to discard expired medical supplies, and failed to permanently affix a narcotic storage box to the refrigerator.Findings include: The facility's policy regarding medication storage and labeling, dated [DATE], revealed that the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Observations in the second floor medication cart on February 4, 2026 at 10:32 a.m. revealed that there was one Insulin Lispro Subcutaneous Solution pen (medication used for diabetes) that had expired on [DATE], and there was one Novolog injection Solution pen (medication used for diabetes) that was open and undated. Interview with Licensed Practical Nurse 3 on February 4, 2026 at 10:35 a.m. confirmed that the Insulin Lispro pen was expired and should have been discarded and that the Novolog pen was open and should have been labeled with the date it was opened.Observations in the third floor medication room on February 4, 2026 at 10:48 a.m. revealed that there was a box of Lorazepam syringes (controlled medication used to treat anxiety) in the refrigerator. The refrigerator was not locked and the box containing the Lorazepam was not permanently affixed to the refrigerator.Interview with Licensed Practical Nurse 4 on February 4, 2026 at 10:48 a.m. confirmed that the medication refrigerator was not locked and that the narcotic box was not permanently affixed to the refrigerator.Interview with the Director of Nursing on [DATE] at 3:21 p.m. revealed that the expired insulin pen should have been discarded, the open insulin pen should have been dated, the narcotic refrigerator should have been locked, and the narcotic box should have been permanently affixed to the refrigerator. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 395393 Page 9 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items that were palatable. Findings include:Interview with a group of residents on February 2, 2026 at 1:30 p.m. revealed that the food delivered to the resident rooms and the dining rooms on their floors was served cold. Interview with Resident 48 on February 2, 2026 at 1:57 p.m. revealed that the food is cold.Interview with Resident 103 on February 2, 2026 at 11:42 a.m. revealed that the food is often cold and tastes bland.Observations in the kitchen for the lunch meal service on February 3, 2026 and 11:56 a.m. revealed that a test tray left the kitchen and arrived on the third floor at 12:14 p.m. The lunch meal on February 2, 2026, consisted of spaghetti and meatballs, vegetable blend, strawberry cake, milk, and juice. Trays were passed to the residents in their rooms and the last resident was served and eating at 12:28 p.m. The test tray on February 2, 2026 at 12:28 p.m. revealed that the temperature of the spaghetti and meatballs was 127.0 degrees Fahrenheit (F), the vegetable blend was 124.0 F, the milk was 44.8 degrees F, and the juice was 45.8 degrees F. The spaghetti, meatballs, and vegetable blend were cool to taste and not palatable.Interview with the Corporate Dietary Manager on February 3, 2026 at 12:30 p.m. confirmed that foods should be served to residents at proper and palatable temperatures. 28 Pa. Code 211.6(b) Dietary Services. Residents Affected - Some 395393 Page 10 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of observations, and staff interviews, it was determined that the facility failed to prepare and store ice under sanitary conditions for one of four ice machines (third floor pantry). Findings include:Observations of the ice machine in the third floor pantry room on February 4, 2026 at 10:41 a.m. revealed that there was no air gap for the drain pipe. The drain pipe traveled down and directly into the drain hole with no air gap present.Interview with the Maintenance Director on February 4, 2026 at 11:05 a.m. confirmed that the drain pipe coming from the ice machine in the third floor pantry was in direct contact with the floor drain, that there was no air gap, and that there should have been an air gap between the end of the pipe and the floor drain.28 Pa. Code 207.4 Ice Containers and Storage. 28 Pa. Code 211.6(f) Dietary Services. 395393 Page 11 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of policy, 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 46 residents reviewed (Resident 92).Findings include: A facility policy for charting documentation dated January 27, 2026, revealed that a complete account of the resident's care, treatment, response to care, signs, symptoms, and the progress will be documented and will be concise, accurate, complete, and use objective terms.A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 92, dated January 13, 2026, revealed that the resident was cognitively intact and had a peg tube (a tube placed directly into the stomach to provide nutrition).Physician's orders for Resident 92 dated October 11, 2025, revealed 240 cubic centimeters of 1.5 Juven (a specialized nutrition power to support healing a build lean body mass) three times a day if the resident ate < 50% of the meal.Review of nurse aide task documents for Resident 92 for January 2026 revealed that the resident ate less than 50% of her meal on January 15, 2026, for breakfast, January 22, 2026, January 5, 2026 for lunch, January 6, 2026 for lunch, January 14, 2026 for lunch, January 19, 2026 for dinner, January 27, 2026 for dinner, and January 31, 2026 for dinner.Review of the Medication Administration Record (MAR) for Resident 92 for January 2026 revealed that on January 15, 2026, she ate 50% of breakfast and did not receive a tube feed. On January 22, 2026, she ate 100% of breakfast and did not receive a tube feed, January 30, 2026, January 5, 2026, she ate 100% of lunch and did not receive a tube feed, Januaryy 6, 2026, she ate 100% of lunch and did not receive a tube feed, January 14, 2026 ate 60% of lunch and did not receive a tube feed, January 19, 2026, ate 50% of dinner and did not receive a tube feed, January 27 2026, ate 65% of dinner and did not receive a tube feed, and on January 31, 2026, ate 50% of dinner. Interview with Nurse Aide 5 on February 5, 2026, at 9:46 a.m., revealed that nurse aide documentation for percent eaten was documented on a sheet of paper on a clipboard in the nurses station for the Licensed Practical Nurse to see the amount eaten prior to the nurse aids documenting in the clinical record.Interview with the Licenses Practical Nurse 1 revealed that she uses the documentation per the sheet in the nurses station to determine the amount eaten, and at times she has collected the tray and documented the % eaten.Interview with the Director of Nursing on February 5, 2026, at 1:29 p.m. confirmed that nurse aide documentation of Resident 92s percent eaten did not match the documentation on her MAR on the above dates and times and should have. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services. 395393 Page 12 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and/or maintain compliance with quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) for the annual survey ending January 10, 2025 and a complaint survey ending March 5, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 5, 2026, identified repeated deficiencies related to safety/accidents, labeling and storage of medications, palatable food, and sanitary food practices. The facility's plans of correction for deficiencies regarding safety/accidents, cited during the survey ending January 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain ongoing compliance regarding safety/accidents.The facility's plans of correction for deficiencies regarding labeling and storage of medications, cited during the survey ending January 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain ongoing compliance regarding the labeling and storage of medications.The facility's plans of correction for deficiencies regarding palatable food, cited during the survey ending January 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain ongoing compliance regarding palatable food.The facility's plans of correction for deficiencies regarding sanitary food practices, cited during the surveys ending January 10, 2025 and March 5, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to maintain ongoing compliance regarding sanitary food practices.Refer to F689, F761, F804, F812.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management 395393 Page 13 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 46 residents reviewed (Resident 103).Findings include:CDC guidance on suspected or confirmed Clostridioides (C. diff, a germ that causes infectious diarrhea and colitis). Facilities were to isolate and initiate contact precautions (infection control measures designed to prevent the spread of germs transmitted through direct or indirect contact with a patient or their environment).The facility's policy regarding isolation and initiating transmission based precautions, dated January 27, 2026, indicated that the transmission based precautions would be utilized when a resident meets the criteria for transmissible infection and the resident has the risk factors that increase the likelihood of transmission. A review of Resident 103's clinical record revealed that she was admitted to the facility on [DATE].Interview and observations with Resident 103 on February 2, 2026, at 11:42 a.m., revealed that she was alert and oriented, able to make her needs known, and understood her medical needs. She stated that she does not attend in person activities because she has C diff. Outside of her room was a sign that said contact precautions that requires facility staff to wear gloves and a gown for care needs.Physician's orders for Resident 103, dated January 28, 2026, included an order for the resident to be administered 125 milligrams of Vancomycin HCL (antibiotic medication) every six hour for 14 days for C. diff. Physician's orders for Resident 103, dated January 28, 2026, included an order for the resident to be provided contact precautions for C. diff.A nursing noted for Resident 103 dated February 2, 2026, indicated that her chemotherapy treatment was changed from February 4, 2026 to February 18, 2026 due to active C. diff infection. Observations of Resident 103's on February 4, 2026, at 1031 a.m. revealed that Nurse Aide 5 entered the room without putting on a gown and gloves. Upon entering the Room Nurse Aide 5 was performing perineal care (cleaning of the genital, groin, and rectal areas to maintain hygiene) and changing Resident 103's adult brief wearing only gloves. Interview with Nurse Aide 5 at the time of the observation confirmed that she did not know that the resident was on contact precautions and she should have asked another staff.Interview with the Director of Nursing on February 5, 2026 at 1:14 p.m. confirmed that Nurse Aide 5 should have donned a gown prior to performing Resident 103's care.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services. Residents Affected - Few 395393 Page 14 of 15 395393 02/05/2026 Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on a review of personnel files as well as interviews with staff, it was determined that the facility failed to ensure that the required In-Service Training was completed for one of four nurse aides reviewed (Nurse Aide 6).Findings include:Review of Nurse Aide 6's personnel file revealed that she was hired on March 28, 2017. Review of her continuing education transcript revealed that she did not have the required 12 hours of Nurse Aide training per year.Interview with the Director of Nursing on February 4, 2026 at 3:33 p.m. confirmed that Nurse Aide 6 failed to complete the necessary 12 hours of training. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development 395393 Page 15 of 15