Health inspection·February 26, 2026

F 0628 Level of Harm - Potential for minimal harm Residents Affected - Many Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on a review of facility policy and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for eleven of eleven months (February 2025 through January 2026).Findings include: Review of the facility policy Transfer and Discharge (including AMA) dated 1/15/26 with a prior review date of 1/16/25, indicated The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manor in which they can understand. The facility will maintain evidence that the notice was sent to the Ombudsman. Federal Regulations further define emergency transfers as, When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer. A request to review facility documents on 2/24/26, of the facility's compliance in notifying the State Ombudsman Office revealed the facility failed to provide documented evidence of notifying the State Ombudsman Office of resident transfers and discharges for the time frame of 1/2025 through 1/2026. During an interview on 2/26/25, at 9:30 a.m., the Nursing Home Administrator confirmed the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division during the past twelve months. 28 Pa. Code 201.18(b)(3)(e)(2) Management. Page 1 of 4 396059 396059 02/26/2026 Concordia at the Cedars 4363 Northern Pike Monroeville, PA 15146

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, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of decreased Capillary Blood Glucose (CBG) levels for two of eight residents reviewed (Residents R3 and R5).Findings include: The Centers for Disease Control define diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds.Review of the facility policy Hypoglycemia Management reviewed 1/16/25 and 1/15/26, indicated the facility will identify residents that are at risk for hypoglycemia and observe them for signs and symptoms of low blood glucose. If the blood glucose reading is 70 mg/dl or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with follow up blood glucoses as indicated, and notify the practitioner of the results as ordered. The blood sugar(s) and treatment will be documented as per facility protocol.Review of the clinical record revealed Resident R3 was admitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and depression. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 12/4/25, indicated the diagnoses remain current.Review of Resident R6 physician's order revealed the following orders:- On 10/10/25, Humalog insulin (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours), inject as per sliding scale: if 0-70 = initiate hypoglycemic protocol.Review of Resident R3's orders failed to indicate an ordered hypoglycemic protocol. Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed the CBG's were as follows: - On 12/11/25, at 7:50 a.m. the CBG was noted to be 69.- On 12/15/25, at 8:36 a.m. the CBG was noted to be 61.Review of Resident R3 eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician order was not followed for hypoglycemic protocol. Review of Resident R3 care plan dated 6/21/25, revealed the following intervention: Monitor/document/report as needed any sign and symptoms of hypoglycemia.Review of a clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and history of falling.Review of the MDS dated [DATE], indicated the diagnoses are Residents Affected - Few 396059 Page 2 of 4 396059 02/26/2026 Concordia at the Cedars 4363 Northern Pike Monroeville, PA 15146

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few current.Review of Resident R5 physician's orders revealed the following orders: - On 1/11/26, Oral hypoglycemic protocol: Blood glucose <45 mg/dl - give 30 g (grams) of carbohydrate (8 oz of juice/soda or 2 tbsp (tablespoon) jelly/sugar). Blood glucose 45-59 mg/dl - give 20 g of carbohydrate (6 0z of juice/soda or 1.5 tbsp jelly/sugar). Blood glucose 60 - 100 mg/dl - give 15 g of carbohydrate (4 oz of juice/soda or 1 tbsp jelly/sugar) as needed for hypoglycemia protocol. Repeat blood glucose level in 15 minutes.- On 1/11/26, Glucagon emergency injection kit one milligram (mg) inject one mg intramuscularly as needed for hypoglycemia protocol. Give if blood glucose is less than 70 mg/dl and resident is unable to swallow/unconscious. Recheck blood glucose in 15 minutes. If still less than 70 mg/dl (after already given glucagon) CALL 911.- On 1/11/26, Humalog insulin per sliding scale: if 0-70 = initiate hypoglycemic protocol.Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed the CBG's were as follows: - On 1/23/26, at 8:14 p.m. the CBG was noted to be 34. - On 1/25/26, at 7:55 a.m. the CBG was noted to be 62.- On 1/26/26, at 7:50 a.m. the CBG was notes to be 57.- On 1/27/26, at 8:15 a.m. the CBG was noted to be 59.- On 1/28/26, at 5:29 a.m. the CBG was noted to be 37.- On 1/28/26, at 12:57 p.m. the CBG was noted to be 67.- On 2/10/26, at 5:02 p.m. the CBG was noted to be 66.On 2/11/26, at 12:54 p.m. the CBG was noted to be 53.- On 2/11/26, at 9:29 p.m. the CBG was noted to be 68.- On 2/16/26, at 1:03 p.m. the CBG was noted to be 67.- On 2/17/26, at 1:23 p.m. the CBG was noted to be 49.- On 2/18/26, at 4:29 p.m. the CBG was noted to be 53.- On 2/21/26, at 8:04 a.m. the CBG was noted to be 66.Review of the eMAR progress notes revealed:- On 1/23/26, at 8:14 p.m. Resident R5 received a glucagon injection. On 1/23/26, at 9:38 p.m. the CBG was 168. Resident was not assessed for hypoglycemia, and the physician was not notified of abnormal results.- On 1/28/26, at 5:29 a.m. Resident R5 received a glucagon injection. On 1/28/26, at 5:42 a.m. the CBG was 168. Resident was not assessed for hypoglycemia, and the physician was not notified of abnormal results. No documentation noted for 1/28/26, CBG of 67.Review of Resident R5's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates.Review of Resident R5 care plan dated 1/12/26, revealed the following intervention: Staff will evaluate resident for signs and symptoms of hypoglycemia.During an interview on 2/25/26, at 2:00 p.m. Licensed Practical Nurse (LPN) Employee E1 stated for diabetic residents with blood sugars under 90 they give the resident juice and recheck the blood glucose in 15 minutes; if the blood glucose was elevated it would depend on the resident's baseline to what number would concern them. If it was elevated over the resident's baseline they would call the physician to get new orders. When asked if they would document, LPN Employee E1 stated they would document in the progress note.During an interview on 2/25/26, at 2:02 p.m. Registered Nurse (RN) Employee E2 stated any blood glucose under 80 they would consider hypoglycemia and would get the resident a snack, juice, or glucagon. They stated blood glucose over 120 they would review the orders for a sliding scale and follow that. They would call the physician if the resident had signs or symptoms, and depended on the resident's baseline. When asked if they would document, RN Employee E2 stated they would document in the progress notes if the blood glucose was super high, they defined super high as any number over the parameter and if the resident was having signs or symptoms.During an interview on 2/25/26, at 2:06 p.m. LPN Employee E3 stated it depends on the order if they call the physician, and it depends on the resident's baseline. They stated they would review the blood glucoses to determine what baseline was. They would follow the physician's orders. If the blood glucose was less than 70 they would give the resident a snack. When asked if they would document, LPN Employee E3 stated they would document everything they did, the resident's signs and symptoms, and the physicians 396059 Page 3 of 4 396059 02/26/2026 Concordia at the Cedars 4363 Northern Pike Monroeville, PA 15146

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few response to their telephone call.During an interview on 2/25/26, at 2:10 p.m. LPN Employee E4 stated for blood glucoses under 90 they would monitor the resident closely for signs and symptoms their glucose level was dropping. For blood glucose levels of 70 - 80, they would give the resident a snack or juice. For elevated blood glucose it would depend on the resident's baseline. For blood glucose over 150 they would monitor the resident and call the physician over 200. They stated they would document in the progress notes and on the shift report for the next shift.During an interview on 2/26/26, at 8:30 a.m. the Medical Director stated he would definitely expect a telephone call for blood glucose results in the 30's. He stated that a lot of the staff notify him via their cell phones. He confirmed the nursing staff needed to document better to take credit for their actions. He confirmed Resident R3 and R5 have not been sent out to the hospital from the facility for hypoglycemia.During an interview on 2/26/26, at 8:45 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physician's orders for Residents R3 and R5.28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services 396059 Page 4 of 4