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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 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

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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.

  • 0558GeneralS&S Dpotential for harm

    F558 - The right to reside and receive services in the facility with reasonable

    Reasonably accommodate the needs and preferences of each resident.

FAQ · About this visit

Common questions about this visit

What happened during the June 17, 2025 survey of CEDAR HILL HEALTHCARE AND REHABILITATION CENTER?

This was a inspection survey of CEDAR HILL HEALTHCARE AND REHABILITATION CENTER on June 17, 2025. 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 June 17, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."

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