Inspection Reports for
Concordia at the Cedars
4363 NORTHERN PIKE,, MONROEVILLE, PA, 15146
Back to Facility Profile30 Reports
Inspection Report — Jan 20, 2026
Complaint Investigation
Date: Jan 20, 2026
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 01/20/2026.
Complaint Details
The inspection was complaint-driven and the submitted plan of correction was determined to be fully implemented.
Findings
The facility was found to have deficiencies related to annual medical evaluations and record entries legibility. The submitted plan of correction was accepted and fully implemented.
Citations (2)
141b1 Annual Medical Evaluation: A resident's most recent medical evaluation was out of date and not documented on the required form.
251b Record Entries Legible: A resident's initial medical evaluation had corrective tape covering an 'X' in a critical eligibility box, violating record entry requirements.
Report Facts
Residents Served: 64
Hospice Current Residents: 10
Residents 60 Years or Older: 64
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Inspection Report — Sep 22, 2025
Complaint Investigation
Date: Sep 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation at Concordia at the Cedars to review compliance with regulations and assess the submitted plan of correction.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The submitted plan of correction was reviewed and determined to be fully implemented.
Findings
The inspection identified multiple deficiencies including tripping hazards in resident rooms, unsecured medications found accessible on the floor, and incomplete resident support plans regarding fall risk. The facility submitted and implemented plans of correction for all deficiencies.
Citations (3)
Numerous tripping hazards present throughout resident bedroom including piles of dirty laundry and debris creating unsafe movement for a resident using a wheelchair and rollator.
An unlocked, unattended, and accessible white pill was found lying on the carpet near the doorway of residents' shared bedroom. This was a repeat violation.
Resident's most recent support plan did not include a description or plan to address resident fall risk despite multiple falls.
Report Facts
Residents Served: 69
Current Hospice Residents: 8
Residents Age 60 or Older: 69
Residents with Mental Illness: 1
Residents with Mobility Need: 10
Residents with Physical Disability: 3
Inspection Report — Sep 4, 2025
Complaint Investigation
Date: Sep 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 09/04/2025.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 68
Current Hospice Residents: 8
Residents Age 60 or Older: 68
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 10
Residents with Physical Disability: 2
Inspection Report — Jun 23, 2025
Complaint Investigation
Date: Jun 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 06/23/2025.
Complaint Details
The inspection was triggered by a complaint, as stated under Inspection Information on page 2.
Findings
Multiple deficiencies were found related to medication security, labeling, following prescriber's orders, and resident records storage. The facility had unlocked medications and resident records accessible, incorrect medication labeling, and failure to follow medication administration orders. Plans of correction were accepted and implemented by 09/22/2025.
Citations (4)
The door to the 2nd floor nurses station was open, unattended and accessible, containing numerous unlocked medications for residents.
A resident's medication label indicated incorrect dosage instructions differing from the prescribed order.
Medications were not administered according to prescriber's orders for multiple residents, including continued administration of discontinued medications and delayed administration.
Resident records were stored unlocked and unattended on the 2nd floor medication cart, including confidential information and narcotic count sheets.
Report Facts
Residents Served: 69
Staffing Hours - Total Daily Staff: 77
Staffing Hours - Waking Staff: 58
Current Hospice Residents: 11
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 8
Residents 60 Years or Older: 69
Residents with Physical Disability: 1
Inspection Report — Dec 3, 2024
Complaint Investigation
Date: Dec 3, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit triggered by a complaint and incident involving alleged resident abuse and mistreatment.
Complaint Details
The visit was complaint-related involving allegations of resident abuse and mistreatment. The abuse allegation was substantiated by the findings, and staff person B was terminated. The facility was found to have delayed reporting the abuse to the local Area Agency on Aging and the Department.
Findings
The inspection found multiple violations including failure to timely report suspected resident abuse, inappropriate and disrespectful treatment of residents by staff, and incomplete resident assessments related to wound care. Staff person B was terminated following these findings.
Citations (4)
Failure to immediately report suspected abuse of a resident as required by law.
Failure to report the incident or condition to the Department’s personal care home regional office within 24 hours.
Resident was treated without dignity and respect, including verbal abuse and inappropriate comments by staff.
Resident's additional assessment was incomplete and did not document wound care needs or home health contact information.
Report Facts
Residents Served: 70
Current Hospice Residents: 14
Residents 60 Years or Older: 70
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person B | Named in multiple findings related to resident abuse, disrespectful treatment, and failure to report incidents. Terminated following investigation. | |
| Staff Person A | Involved in the incident with the resident; notified medication technician about the abuse incident. | |
| Staff Person C | Medication Technician | On duty during the incident; was notified about the abuse incident. |
| Staff Person E | Direct Staff | Provided incontinence care to resident and intervened during mistreatment by Staff Person B. |
Inspection Report — Sep 12, 2024
Complaint Investigation
Date: Sep 12, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Concordia at the Cedars.
Complaint Details
The visit was complaint-related and substantiated by the observation of staff misconduct causing resident distress.
Findings
The inspection found a violation of resident dignity and respect when a staff member was observed using profanity and arguing on the phone while assisting a resident, causing distress. The staff member was suspended and terminated, and corrective actions including resident interviews and staff education were implemented.
Citations (1)
A staff member was assisting a resident while using profanity and arguing on the phone, causing the resident to feel scared and not acknowledging the resident's distress.
Report Facts
Residents Served: 69
Current Residents in Hospice: 12
Residents Age 60 or Older: 69
Residents with Mental Illness: 1
Residents with Physical Disability: 1
Residents with Mobility Need: 15
Inspection Report — Mar 4, 2024
Complaint Investigation
Date: Mar 4, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 03/04/2024.
Complaint Details
The inspection was complaint-driven and incident-related, with a follow-up plan of correction submission required and completed.
Findings
The inspection identified multiple deficiencies including misuse of resident funds by a staff member, incorrect medical evaluation dates, incomplete medication administration records, and inaccurate support plan documentation regarding financial management. The facility submitted a plan of correction which was fully implemented by 04/16/2024.
Citations (4)
Misuse of resident funds by a direct care staff person soliciting residents for a school fundraiser and improper handling of resident payments.
Resident medical evaluation was not conducted within the required timeframe prior to or shortly after admission.
Medication administration record (MAR) was not initialed by staff on multiple dates for a resident receiving anticoagulant injections.
Resident support plan inaccurately documented family as managing finances when direct care staff were responsible.
Report Facts
Residents Served: 65
Current Hospice Residents: 10
Residents 60 Years or Older: 65
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 9
Residents with Physical Disability: 1
Inspection Report — Jan 8, 2024
Follow-Up
Date: Jan 8, 2024
Visit Reason
The inspection visit on 01/08/2024 was a partial, unannounced follow-up inspection triggered by a complaint to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related, focusing on verifying correction of deficiencies in resident assessments and support plan signatures. The submitted plan of correction was accepted and fully implemented.
Findings
The facility was found to have fully implemented the submitted plan of correction related to resident assessments and support plan signatures. The inspection confirmed compliance with regulations after addressing deficiencies in resident mobility assessments and support plan documentation.
Citations (2)
Resident significant change assessment showed discrepancies in mobility assistance needs and lacked hospice contact information.
Resident annual support plan was not signed by the assessor or resident, with no indication of refusal or inability.
Report Facts
Residents Served: 60
Current Hospice Residents: 9
Residents 60 Years or Older: 61
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 8
Residents with Physical Disability: 2
Inspection Report — Oct 17, 2023
Follow-Up
Date: Oct 17, 2023
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with corrective actions including staff termination, resident interviews, and staff education to prevent neglect and abuse.
Citations (1)
Resident #3 was neglected when staff person B failed to provide incontinence care and transfer assistance as required, resulting in the resident being soaked with urine.
Report Facts
Residents Served: 64
Current Residents in Hospice: 10
Residents Age 60 or Older: 64
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 9
Residents with Physical Disability: 2
Resident Interviews Planned: 10
Resident Interviews per Week: 3
Resident Interviews per Month: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Hofmann | Administrator | Administrator responsible for conducting resident interviews and staff education as part of plan of correction |
Inspection Report — Sep 26, 2023
Renewal
Date: Sep 26, 2023
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons.
Findings
The inspection identified multiple deficiencies including lack of privacy signage for video surveillance, missing rabies vaccination certificate for a cat, failure to use alternate exit routes during fire drills, incomplete medical evaluations for residents, and failure to follow prescriber's orders for insulin administration. Plans of correction were accepted and implemented by 10/30/2023.
Citations (6)
The home is video recording the front entrances without posted signs indicating surveillance.
The home does not have a current certificate of rabies vaccination for a cat named Pumpkin.
Alternate exit routes were not used during fire drills from 9/29/22 through 9/8/23.
Medical evaluation for resident #1 is missing height and weight information.
Medical evaluation for resident #2 is missing height information.
Resident #3 did not receive the 3:00 p.m. blood glucose reading until late and was administered incorrect insulin dose; physician was not notified of high blood glucose reading.
Report Facts
Residents Served: 69
Current Hospice Residents: 14
Residents with Mental Illness: 2
Residents with Mobility Need: 12
Residents with Physical Disability: 2
Inspection Report — Jul 31, 2023
Date: Jul 31, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 62
Current Hospice Residents: 10
Residents 60 Years or Older: 62
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 11
Residents with Physical Disability: 2
Inspection Report — Jun 21, 2023
Follow-Up
Date: Jun 21, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for previous violations.
Findings
The facility was found to have repeated violations related to resident abuse reporting, written incident reporting, activities of daily living assistance, and treatment of residents with dignity and respect. The plan of correction was accepted and fully implemented by 07/24/2023, including termination of the involved staff member and staff education.
Citations (4)
Failure to immediately report suspected abuse of a resident to the Area Agency on Aging.
Failure to report the incident to the Department’s personal care home regional office or complaint hotline within 24 hours.
Resident #2 was left unattended in a wheelchair and staff refused to assist with propelling the wheelchair.
Staff person A screamed at resident #1 and treated residents without dignity and respect, including telling resident #3 to go to bed against their wishes.
Report Facts
Residents Served: 70
Total Daily Staff: 81
Waking Staff: 61
Current Hospice Residents: 12
Residents Age 60 or Older: 70
Residents with Mental Illness: 2
Residents with Mobility Need: 11
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in multiple findings related to abuse, incident reporting, and treatment of residents; terminated after investigation. |
Inspection Report — Feb 21, 2023
Follow-Up
Date: Feb 21, 2023
Visit Reason
The inspection visit occurred as a follow-up to review the submitted plan of correction related to an incident involving resident abuse and treatment of residents.
Findings
The facility was found to have previously failed to report suspected abuse timely and had incidents of staff speaking disrespectfully to a resident. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Citations (2)
Failure to immediately report suspected abuse of a resident as required by regulations.
Staff member raised voice and spoke disrespectfully and condescendingly to resident regarding operation of TV remote.
Report Facts
Residents Served: 66
Current Hospice Residents: 13
Residents 60 Years or Older: 66
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 11
Residents with Physical Disability: 2
Notice — Mar 8, 2022
Date: Mar 8, 2022
Visit Reason
The document serves to notify Concordia at the Cedars that their request to waive certain Pennsylvania Code regulations regarding preadmission screening and medical evaluation forms is granted under specified conditions.
Findings
The waiver allows the facility to use preadmission screening and medical evaluation forms from Point, Click, Care instead of the Department’s forms. The Department will review compliance with this waiver during the annual inspection and may terminate the waiver or take licensing action if conditions are not met.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Parisi | Bureau Director, Human Services Licensing | Signed the waiver approval letter |
Inspection Report — Feb 9, 2022
Renewal
Date: Feb 9, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility Concordia at the Cedars on 02/09/2022 and 02/10/2022.
Findings
Several deficiencies were cited related to fire safety and documentation, including inadequate lighting signage on emergency exit doors, failure to conduct an unannounced fire drill in January 2022, outdated fire safety inspection and drill, prolonged evacuation times during fire drills in 2021, and an incomplete preadmission screening form for a resident.
Citations (5)
Signs on first floor emergency exit doors limited access to exit with 'STOP - Do Not Enter - Authorized Personnel Only' signs.
An unannounced fire drill was not conducted in January 2022.
The last fire safety inspection and fire drill by a fire safety expert was conducted on 5/28/2020, not within the past year.
Evacuation times for monthly fire drills in 2021 exceeded 2 minutes and 30 seconds, with times ranging from 4 to 8 minutes, and evacuation times were rounded rather than exact.
Resident #2's preadmission screening form was not dated, making it impossible to determine if it was completed before admission.
Report Facts
Residents Served: 55
Current Hospice Residents: 11
Staffing Hours: 78
Waking Staff: 59
Evacuation Times: 6
Evacuation Times: 8
Evacuation Times: 7
Inspection Report — May 4, 2021
Renewal
Date: May 4, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility on 05/04/2021, 05/05/2021, and 05/07/2021 to assess compliance with Department statutes and regulations.
Findings
The inspection identified several deficiencies including unlabeled poisonous materials, unlocked poisonous materials accessible to residents, inaccurate medical evaluations, and medication labeling errors. Plans of correction were accepted and documented as implemented with ongoing audits and staff training.
Citations (4)
Unlabeled 32-ounce spray bottle containing an unknown clear liquid stored with other poisons in the laundry room.
Multiple unlocked, unattended, and accessible poisonous materials in activity storage room and dining room cabinets.
Medical evaluation for resident #2 indicated need for secured dementia care unit (SDCU), but the home does not have a SDCU.
Medication label for resident #2's Risperidone indicated incorrect dosage (twice daily instead of once daily).
Report Facts
Residents Served: 52
Current Hospice Residents: 8
Total Daily Staff: 68
Waking Staff: 51
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Notice — Apr 30, 2021
Date: Apr 30, 2021
Visit Reason
The document serves as a response to the renewal application submitted on February 9, 2021, for the operation of the Personal Care Home and informs that a regular license is being issued. It also notifies that an onsite annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it is a licensing and renewal notice confirming the issuance of a regular license and outlining the requirement for a future annual inspection.
Report Facts
Inspection Report — Feb 21, 2020
Renewal
Date: Feb 21, 2020
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance with licensing regulations and verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection included a complaint investigation component, but the report does not explicitly state the substantiation status of the complaint.
Findings
The facility had multiple deficiencies related to medication storage, staff training, environmental safety, resident assessments, and documentation. All identified deficiencies had approved plans of correction that were implemented by the time of the follow-up review.
Citations (14)
A medication cart narcotic record binder was found unlocked and accessible with multiple resident names and medications listed.
Direct care staff did not receive required 12 hours of annual training covering medication self-administration, resident needs, dementia care, infection control, personal care, and safe management techniques.
Direct care staff did not receive required annual training on fire safety, emergency preparedness, resident rights, protective services, and falls prevention.
A 28-fluid ounce spray bottle of fabric refresher was found unlocked and accessible in a resident's bathroom, posing a poisoning risk.
Room #100 flooring required replacement to eliminate urine odor.
Two loveseats and one couch were removed from the campus due to safety concerns.
Resident room #215 window screen was missing and required replacement.
Residents #1, #11, and #12 lacked operable sources of light at bedside.
The facility lacked a current fire safety inspection and fire drill conducted by a fire safety expert as required.
Resident #11 did not have a medical evaluation completed within required timeframes.
Resident #13's initial medical evaluation was incomplete, missing height information.
Residents #1, #6, #9, and #13 had delayed or incomplete medical evaluations and assessments.
Resident #9's Atenolol medication was not removed from the medication cart until the inspection date.
The facility did not complete a pre-screening form for resident #13 admitted on 10/24/19.
Report Facts
Residents Served: 69
Current Hospice Residents: 6
Staff Training Hours Required: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ley | PC Administrator | Signed multiple plans of correction and was responsible for education and audits related to deficiencies |
Notice — Jan 29, 2020
Date: Jan 29, 2020
Visit Reason
The document serves as a renewal notification for the Personal Care Home license for Concordia at the Cedars, confirming the issuance of a regular license following the renewal application.
Findings
No inspection findings are reported in this document. It states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Inspection Report — Oct 24, 2019
Complaint Investigation
Date: Oct 24, 2019
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced notice on October 24, 2019.
Complaint Details
The inspection was complaint-driven and unannounced. The plan of correction was approved and fully implemented by 11/13/19.
Findings
The submitted plan of correction was found to be fully implemented as of November 13, 2019. The inspection identified issues related to medication administration and resident assessment documentation.
Citations (2)
Resident #1 had a positive UTI test on 8/15/19, but the home did not obtain the prescribed medication until 8/18/19 evening.
The assessment for resident #1 dated 7/11/19 did not address the diagnosis of chronic kidney disease as indicated in a physician order dated 6/17/19.
Report Facts
Residents Served: 67
Total Daily Staff: 89
Waking Staff: 67
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Physical Disability: 2
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 22
Residents Age 60 or Older: 67
Inspection Report — Aug 7, 2019
Renewal
Date: Aug 7, 2019
Visit Reason
The inspection was a renewal inspection conducted on August 7 and 8, 2019, to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
Violations of the Personal Care Homes regulations were found, including deficiencies in staff annual training, safe management techniques, documentation of training hours, medication administration, environmental safety, and resident medical evaluations. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (14)
Direct care staff persons A and B did not receive required annual training on topics including safe management techniques and meeting residents' needs during the 2018 training year.
Staff training records for 2018 lacked documentation of course lengths for multiple required training topics for staff persons A and B.
An Airwick Air Freshener was unlocked and accessible to residents in the men's common bathroom without assessment of residents' ability to recognize and use poisons safely.
Handrails to the right of the elevator and on the steps to the right of the building were not securely attached and the support bar was rusted and broken.
A loud buzzing sound was present when the light fixture in resident #6's bedroom was turned on.
The home's dryer exhaust vent had lint accumulation and over 20 cigarette butts in the cement pit outside the building.
No thermometer was present in the 1st floor kitchenette refrigerator and the small refrigerator by the kitchen stove measured 46 degrees Fahrenheit.
Resident #4's medical evaluation dated 5-7-19 was incomplete, missing information on medication self-administration ability, special health or dietary needs, mobility needs, health status, and cognitive functioning.
Resident #2's most recent medical evaluation was outdated, completed on 1-7-19, with a previous evaluation dated 11-27-17.
Resident #5's medication administration was not consistent with physician orders; insulin administration was inaccurate and blood sugar monitoring was incomplete.
Resident #3 was admitted on 2-7-19 but assessment was not completed until 3-1-19.
Resident #4 was admitted on 6-20-19 but no support plan was completed until 8-12-19.
Resident #6's catheter care needs were not fully documented in the most recent assessment dated 10-12-18.
Staff person A had not completed an annual practicum since 2017 but administered numerous medications to resident #5 on 8-6-19.
Report Facts
Residents Served: 65
Staff: 89
Waking Staff: 67
Current Hospice Residents: 6
Residents Age 60 or Older: 65
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 24
Residents with Physical Disability: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ley | Administrator | Signed multiple plans of correction and legal entity representative |
Notice — Feb 6, 2019
Date: Feb 6, 2019
Visit Reason
The document is a renewal approval letter for the Personal Care Home license of Concordia at the Cedars, confirming receipt of the renewal application and informing about the upcoming annual inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms that a regular license is being issued in response to the renewal application.
Inspection Report — Aug 24, 2018
Renewal
Date: Aug 24, 2018
Visit Reason
The inspection was conducted as a renewal and complaint investigation for Concordia at the Cedars personal care home.
Complaint Details
The inspection included a complaint investigation as indicated by the reason for inspection and findings related to unlocked confidential records, unlocked medications, and fire safety concerns.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including issues with posting of licensing documents, confidentiality of resident records, direct care staff training, locked storage of medications, fire safety drills, and sanitary conditions. Plans of correction were submitted and approved for all violations.
Citations (15)
Regulation 2600.3(c): The Chapter 2600 regulation book was posted behind a locked glass cabinet and not accessible to residents.
Regulation 2600.17: Resident records were found unlocked, unattended, and contained confidential documents in the End Room on the second floor.
Regulation 2600.65(d): Direct care staff hired after April 24, 2006 provided unsupervised ADL services without completing the required direct care competency test until 7/20/18.
Regulation 2600.65(e): Direct care staff B, hired 3/12/16, only received 8 hours of annual training in 2017 instead of the required 12 hours.
Regulation 2600.65(f): Training documents for direct care staff B's Older Adult Protective Services Act and falls prevention trainings did not include length of courses.
Regulation 2600.82(c): Poisonous materials were unlocked and accessible to residents in the End Room, including povidone-iodine swabs.
Regulation 2600.85(a): A 6 inch long smear of feces was found on the shower wall in the private bathroom of room 215.
Regulation 2600.88(a): The second floor fire doors between the business office and short hallway did not fully close.
Regulation 2600.90(a): The home's first aid kit did not contain eye protection.
Regulation 2600.107(f): No bedside light source was within reach of the resident's bed in room 105.
Regulation 2600.121(a): A wooden baby gate was blocking the doorway to room 205, obstructing egress routes.
Regulation 2600.132(c): The home did not record fire drill times in hours and minutes on specified dates.
Regulation 2600.132(d): Resident #4 was not evacuated from their room during fire drills and was assessed as totally immobile.
Regulation 2600.183(b): A refrigerator containing resident medications was unlocked and accessible in the End Room.
Regulation 2600.183(b): Resident #8's Lantus Solostar insulin pen was dispersed on 7/17/18 and lacked open date documentation.
Report Facts
Number of Residents Served: 66
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 20
Number of Residents 60 Years or Older: 66
Number of Residents with Mobility Need: 19
Total Daily Staff: 85
Walking Staff: 54
Inspection Report — May 30, 2018
Routine
Date: May 30, 2018
Visit Reason
The Department's Bureau of Human Services representatives conducted an inspection of the facility on May 30, 2018.
Findings
No regulatory violations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Mazza | Human Services Licensing Supervisor | Signed the inspection report letter. |
Notice — Jan 30, 2018
Date: Jan 30, 2018
Visit Reason
This document serves as a renewal notification and license issuance for Concordia at the Cedars Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal and certificate of compliance.
Report Facts
Inspection Report — Sep 7, 2017
Renewal
Date: Sep 7, 2017
Visit Reason
The inspection was conducted as an annual licensing inspection with renewal and complaint triggers.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including missing resident contracts, unsecured poisonous materials, lack of monthly fire drills, incomplete fire drill records, and medication administration documentation errors. Plans of correction were submitted with partial implementation progress noted.
Citations (7)
55 Pa.Code 2600.25(b) - Resident-home contracts were not signed by residents #1, #2, #3, #4, and #5.
55 Pa.Code 2600.82(c) - Poisonous materials were unlocked and accessible to residents, including Lysol and disinfectants.
55 Pa.Code 2600.132(a) - No fire drill was conducted in September 2016.
55 Pa.Code 2600.132(c) - Fire drill records lacked exit routes and only indicated residents were evacuated to safe zones.
55 Pa.Code 2600.132(d) - Fire safety expert letter did not specify fire-safe areas for 2017 fire drills.
55 Pa.Code 2600.185(a) - Resident #4's glucometer was not set to the current date and time; narcotics count sheet discrepancies noted for resident #7.
55 Pa.Code 2600.187(a) - Medication records for resident #8 lacked proper documentation and staff initials for administration.
Report Facts
Total Daily Staff: 82
Waking Staff: 62
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 15
Residents 60 Years or Older: 72
Residents with Mental Illness: 1
Residents with Mobility Need: 10
Residents with Physical Disability: 2
Medication tablets resident #7 count: 47
Medication units administered resident #3: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Thompson | Administrator, LPN, PCHA | Named as legal entity representative signing plans of correction and involved in findings. |
| Michael Marini | Inspector | Conducted the inspection on 09/07/2017. |
| Josh Hoover | Inspector | Conducted the inspection on 09/07/2017. |
Notice — Jan 31, 2017
Date: Jan 31, 2017
Visit Reason
This document serves as a renewal notification and certificate of compliance for Concordia at the Cedars Personal Care Home, confirming the facility's license to operate and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and outlines the Department's plan to conduct an annual inspection within the next year.
Report Facts
Notice — Dec 28, 2016
Date: Dec 28, 2016
Visit Reason
The document serves to notify Concordia at the Cedars that a waiver request related to admission and resident medical evaluation requirements has been granted under specified conditions.
Findings
The Department determined that the facility requires a waiver for specific sections of 55 Pa.Code Chapter 2600 related to admission and resident medical evaluation and health care. The waiver is granted with conditions and will be reviewed annually during the facility's annual inspection.
Inspection Report — Aug 10, 2016
Annual Inspection
Date: Aug 10, 2016
Visit Reason
The inspection was conducted as an annual licensing inspection with reasons including renewal and complaint investigation.
Complaint Details
The inspection included a complaint investigation as indicated by the reason for inspection. Specific substantiation status is not stated.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including improper sanitary conditions related to shared glucometers, lint accumulation in dryer lint traps, outdated medical examinations, and incomplete documentation of psychological services in resident support plans.
Citations (4)
55 Pa.Code 2600.85(a) - Sanitary conditions were not maintained as glucometers were shared among residents and used for multiple residents without proper labeling.
55 Pa.Code 2600.105(g)(1) - Lint accumulation of approximately 1/8 inch was found in the lint trap of the dryer in the first floor laundry room, posing a fire hazard.
55 Pa.Code 2600.141(b)(1) - Resident #9 did not have a medical examination completed within the past year; last exam was on 2015-03-12.
55 Pa.Code 2600.227(d) - Resident #10's support plan dated 2015-01-31 did not include documentation of psychological services received since 2015-10-09.
Report Facts
Number of Residents Served: 70
Number of Current Hospice Residents: 9
Number of Residents 60 Years or Older: 67
Number of Residents with Mobility Need: 16
Number of Residents with Physical Disability: 1
Number of Residents Served for Blood Glucose Testing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Thompson | Personal Care Administrator | Named as Administrator and signer of plans of correction |
| Courtney Barry | On-site inspector conducting the inspection | |
| Katie Bedford | On-site inspector conducting the inspection |
Inspection Report — Feb 10, 2016
Renewal
Date: Feb 10, 2016
Visit Reason
The document is a renewal license issued to Concordia at the Cedars for operation as a Personal Care Home. The Department advises that an onsite annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It is a license renewal notice confirming the facility's authorized capacity and regulatory compliance requirements.
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