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Inspection visit

Inspection

CEDAR HILL HEALTHCARE AND REHABILITATION CENTERCMS #3956201 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and investigative documents, it was determined that the facility failed to provide quality of care with an unlicensed employee providing medications to six residents. This was identified as a past non-compliance for six of six residents (Resident R1, R2 R3, R4, R5 and R6). Residents Affected - Few Findings include: Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Review of the job description for NA (Nursing Assistant) indicated job functions to include: duties and responsibilities, administrative, committee, personnel, and specific job function, staff development, competency, safety, equipment & safety functions, financial responsibilities, customer service and resident rights. Giving medications to residents was not included on the nurse Assistant job description. Review of the job description for LPN (Licensed Practical Nurse) indicated: Drug Administration Function: Prepare and administer medications as ordered by the physician. Ensure that direct nursing care is provided by a licensed nurse. Education: Must possess at a minimum a Nursing degree from an accredited college or university, or graduate from an approved LPN/LVN/RNM program. Review of facility documentation submitted to the State Survey Agency indicated: It was reported to the DON (Director of Nursing ) on [DATE], by an agency nurse that over the weekend a co-worker, NA Employee E1, who has been function as an agency NA made the comment if there is a call-off they are not taking a cart . The DON initiated an investigation and discovered that NA Employee E1, had worked at the facility as an LPN on [DATE], and [DATE]. The DON then contacted the agency and was told that NA Employee E1 was employed as a Nurse Aide through the agency. The agency confirmed that they were scheduled to work on [DATE], and [DATE]. During an on-site investigation [DATE], the following was documented on the facility investigation: Employee E2 LPN states that NA Employee E1 kept saying that they did not want to take a cart on the next shift as a nurse. Employee E2 LPN questioned about why NA Employee E1 would say that, and NA Employee E1 said she had worked here before as a Nurse and that they are a LPN. After the conversation DON pulled staffing sheets for the past month and found out that NA Employee E1 was handwritten into the schedule as a nurse on [DATE], 3pm to 11pm and was also on the schedule [DATE], 11pm - 7am. Agency for NA Employee E1 was contacted and confirmed they had her as a Nurse Aide, but did not have (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395620 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hill Healthcare and Rehabilitation Center 951 Brodhead Road Coraopolis, PA 15108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684 her listed as an LPN. Level of Harm - Minimal harm or potential for actual harm Results of investigation failed to show that NA Employee E1 had a LPN current or expired. On [DATE], the facility initiated a plan of correction that included: Residents Affected - Few Investigation determined that NA Employee E1 misinformed the scheduler that they were a nurse. Agency's providing staff to the facility were reduced from 7 to three staffing agencies. Resident were assessed by Unit Manager and DON and no adverse effects noted. Reviewed with Medical Director. Interim scheduler and unit managers educated that the schedule could not be changed without approval by DON/NHA. All agency nursing personnel credentials have been audited to ensure the professional capacity in which they are working g matches the credentials in their file. No further issues were found. All credentials are checked by scheduler and nursing prior to them working in facility. The Moon Twp Police were notified and report was filed. The Board of Nursing was contacted via phone and email. Audits were conducted for agency staff credentials 3x peer week for 4 weeks then weekly x 4 weeks to ensure the practice does not recur. Audits started on [DATE], and were completed on [DATE]. During an interview on [DATE], at approximately 10:30 a.m. The DON confirmed that the facility failed to provide quality of care with an unlicensed employee providing medications to six of six residents reviewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395620 If continuation sheet Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

FAQ · About this visit

Common questions about this visit

What happened during the February 28, 2024 survey of CEDAR HILL HEALTHCARE AND REHABILITATION CENTER?

This was a inspection survey of CEDAR HILL HEALTHCARE AND REHABILITATION CENTER on February 28, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CEDAR HILL HEALTHCARE AND REHABILITATION CENTER on February 28, 2024?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.