F 0558
Reasonably accommodate the needs and preferences of each resident.
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, review of resident council meeting minutes, review of grievance logs, observations,
staff and resident interviews it was determined that the facility failed to accommodate the call bell needs for
four of nine residents (Resident R2, R3, R4 and R7)
Residents Affected - Few
Findings include:
Review of facility policy Call Lights last reviewed 4/2/25, indicated a call light system is used by this facility
to respond to the resident request and needs. Answer the resident's call as soon as possible.
Review of the facility policy Call Light Response last reviewed 4/2/25, indicated staff will respond to the call
light and the residents request and needs in a timely manner.
Review of the facility policy Flow of Care last reviewed 4/2/25, indicated care will be provided to residents,
as needed 24 hours a day to attain and maintain the highest level of functioning. The flow of care is to be
implemented on a continuous basis to promote quality of life with the resident. Call light within reach for all
residents and answered timely.
Review of Resident council meeting minutes dated 4/14/25, indicated a concern about call bells being
answered timely.
Review of Resident council meeting minutes dated 5/19/25, indicated a concern about call bells being
answered timely.
Review of Resident council meeting minutes dated 6/9/25, indicated a concern about call lights being
answered timely.
Review of grievance log for 4/9/25, indicated a concern completed by family member for call bell times.
Review of the admission record indicated Resident R4 was admitted to the facility on [DATE].
Review of Resident R4's MDS (minimum data set a periodic assessment of needs) dated 5/15/25, indicated
the diagnosis of deep vein thrombosis (DVT-blood clot) multiple sclerosis (MS- autoimmune disease that
affects the brain and spinal cord) and reduced mobility. Section C -Cognitive Patterns Brief Interview for
Mental Status (BIMS- tool used to screen and identify the cognition condition of a resident) indicated a
score of 15 intact cognition.
(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 3
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
06/17/2025
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 0558
0-7 Severely impaired cognition
Level of Harm - Minimal harm
or potential for actual harm
8-12 moderately impaired cognition
13-15 intact cognition
Residents Affected - Few
Review of Resident R4's care plan date initiated 9/27/23, indicated Focus: Resident R4 has bowel
incontinence. Interventions that include but not inclusive to check resident every two hours and assist with
toileting as needed
During an interview completed on 6/17/24 at 10:38 a.m. upon asking Resident R4 concerning call bell
response times replied, I have waited in the evening for over a hour, it happens often, a couple of times a
week.
Review of the admission record indicated Resident R3 was admitted to the facility on [DATE].
Review of Resident R3's MDS dated [DATE], indicated the diagnosis of anemia (low iron in the blood),
heart failure (heart doesn't pump the way it should) and high blood pressure. Section C Cognitive Patterns
BIMS score indicated a score of 15 (intact cognition).
Review of Resident R3's care plan date initiated 11/29/22, indicated at risk for bladder incontinence related
to impaired mobility. Interventions include but not inclusive to Check every 2-3 hours and as required for
incontinence.
During an interview completed on 6/17/24, at 10:49 a.m. upon asking Resident R3 concerning call bell
response times replied, I use the urinal at night, about a month ago I put my light on for someone to empty
it, no one came in so I used a cup to urinate in, I have two urinals now.
Review of the admission record indicated Resident R7 was admitted to the facility on [DATE].
Review of Resident R7's MDS) dated [DATE], indicated the diagnosis of cancer, high blood pressure and
diabetes (high sugar in the blood) Section C Cognitive Patterns BIMS score indicated a score of 15 (intact
cognition).
Review of Resident R7's care plan date initiated 10/11/22 indicated Resident R7 has an ADL Self Care
Performance Deficit related to decreased mobility, osteoarthritis, chronic Pain, morbid obesity. Interventions
that included but not inclusive to requires setup and clean-up assist with urinal usage and requires
extensive assist of one staff after episodes of bowel incontinence.
During an interview completed on 6/17/25, at 11:05 a.m. upon asking Resident R7 concerning call bell
response time replied, it varies, the problem is when they use the agency staff, I have waited as long as two
hours.
Review of the admission record indicated Resident R2 was admitted to the facility on [DATE].
Review of Resident R2's MDS (minimum data set a periodic assessment of needs) dated 5/10/25, indicated
a diagnosis of cancer, hypertension (high blood pressure) and diabetes (high sugar in the blood). Section C
Cognitive Pattern- BIMS indicated a score of 11 (moderately impaired cognition).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395620
If continuation sheet
Page 2 of 3
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
06/17/2025
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident R2's care plan date initiated 5/16/24, indicated ADL function deficit as evidenced by
resident needing supervision/touch assist to needing substantial/total dependence with ADLS. Interventions
include but not inclusive to Check for incontinence and change brief every 2 hours and as needed.
Encourage resident to ask for assistance. Keep call light within reach
During an interview completed on 6/17/25, at 11:20 a.m. upon asking Resident R2 concerning call bell
response time replied, Sunday during midnight shift I had an accident, I waited well over an hour, it was too
long I had diarrhea, a man finally came in and helped me he gave me a complete bed bath.
Review of the admission record indicated Resident R1 was admitted to the facility on [DATE].
Review of Resident R1's MDS dated [DATE] indicated the diagnosis anemia, high blood pressure and
diabetes. Section C Cognitive Patterns BIMS score indicated a score of 15 (intact cognition).
During an interview completed on 6/17/25, at 11:22 a.m. Resident R1 (Resident R2's roommate) stated I
went out to the nursing station that night, they told me to put the call light on and they would get someone,
we waited over an hour.
During an observation completed on 6/17/25, at 11:22 a.m. the call light was activated in room [ROOM
NUMBER] at 11:22 a.m. and was answered at 11:39 a.m.
During an interview completed on 6/17/25, at 11:39 a.m. Nurse Aide Employee E6 confirmed the call light
was answered at 11:39 a.m. with a wait time of 17 minutes.
During an interview completed on 6/17/25, at 12:56 a.m. the Director of Nursing confirmed that the facility
had received some complaints concerning the weekend call bell timeliness and indicated she had emailed
the staff to remind that they need to be rounding and answering the call lights timely.
During an interview completed on 6/17/25, at 1:30 p.m. the Nursing Home Administrator confirmed that the
facility failed to accommodate the call bell needs for four of nine residents (Resident R2, R3, R4 and R7)
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395620
If continuation sheet
Page 3 of 3