Deficiencies per Year
24
18
12
6
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 58
Capacity: 79
Deficiencies: 7
Jun 3, 2025
Visit Reason
The inspection was conducted as a renewal, complaint, and incident investigation at THE WOODS AT CEDAR RUN facility on 06/03/2025 and 06/04/2025.
Findings
The inspection found multiple deficiencies including failure to conspicuously post a waiver, resident abuse involving inappropriate staff conduct, unsafe resident personal equipment, unsecured medications, failure to follow prescriber's orders, and incomplete preadmission screening documentation. Plans of correction were accepted and fully implemented by 07/17/2025.
Complaint Details
The inspection included complaint investigation related to resident abuse involving inappropriate communication and conduct between staff and resident, which resulted in staff termination.
Deficiencies (7)
| Description |
|---|
| Failure to publicly and conspicuously post a waiver for staff member's non-US education. |
| Resident abuse involving inappropriate text messages and sending naked pictures from staff to resident. |
| Uncovered bedside mobility device posing potential limb or head entrapment risk. |
| Unlocked and accessible medications in resident's bathroom cabinet without assessment for self-administration. |
| Medications not current or without physician orders kept in resident's bathroom cabinet. |
| Failure to follow prescriber's orders resulting in residents not receiving prescribed medications and supplements. |
| Preadmission screening form incomplete, missing date of completion. |
Report Facts
License Capacity: 79
Residents Served: 58
Residents in Secured Dementia Care Unit: 15
Current Hospice Residents: 8
Total Daily Staff: 79
Waking Staff: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Operations Officer | Named in multiple findings including posting waiver, abuse investigation, medication management, and education. | |
| Maintenance Director | Removed unsafe bedside mobility device from resident's bed. | |
| Resident Wellness Director | Involved in medication management and education, and approval of enabler bars. | |
| Med Tech | Named in medication error finding related to Ensure supplement. |
Inspection Report
Follow-Up
Census: 64
Capacity: 79
Deficiencies: 1
Mar 19, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation and a follow-up to verify the implementation of a previously submitted plan of correction.
Findings
The plan of correction related to unobstructed egress in the secured dementia care unit was found to be fully implemented. The inspection noted that a chair, bench, and trashcan had previously blocked egress routes but were promptly removed, and staff were trained to prevent future blockages.
Complaint Details
The visit was complaint-related and included a follow-up to verify correction of cited deficiencies. The plan of correction was accepted and fully implemented.
Deficiencies (1)
| Description |
|---|
| A chair blocked egress from the sunroom in the secured dementia care unit to the gated courtyard. A bench and a metal trashcan blocked egress from the gated courtyard to the back of the home. |
Report Facts
License Capacity: 79
Residents Served: 64
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 11
Residents Age 60 or Older: 63
Residents with Mobility Need: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Med Tech | Med Tech on duty moved the chair blocking the exit door during the inspection | |
| Director of Maintenance | Director of Maintenance moved the bench and trashcan blocking egress routes |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 79
Deficiencies: 16
Nov 20, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 11/20/2024 and 12/05/2024.
Findings
The facility was found to have multiple violations including failure to report suspected resident abuse, medication errors, confidentiality breaches, improper medication storage and labeling, failure to follow prescriber's orders, and inadequate resident assessments. Several staff members were terminated due to noncompliance. Plans of correction were accepted and implemented with ongoing monitoring and training.
Complaint Details
The visit was complaint-related with substantiated findings of abuse, neglect, medication errors, and regulatory noncompliance.
Deficiencies (16)
| Description |
|---|
| Failure to immediately report suspected resident abuse and comply with reporting requirements. |
| Failure to report incidents to the Department within required timeframes. |
| Resident records were unlocked, unattended, and accessible to unauthorized persons. |
| Resident abuse including verbal abuse, neglect, and intimidation by staff members. |
| Detection of marijuana odor in the wellness office indicating possible staff drug use. |
| Direct care staff providing unsupervised ADL services without completing required training. |
| Resident initial medical evaluation did not include medical information pertinent to diagnosis and treatment in case of emergency. |
| Prescription medications and syringes were found unlocked and unattended in resident rooms. |
| Expired and discontinued medications were found in medication carts and storage areas. |
| Medications were not properly labeled with resident name, prescription date, dosage, instructions, or prescriber information. |
| Over-the-counter medications and CAM were not labeled with resident names. |
| Failure to implement safe storage, access, security, and distribution procedures for medications and medical equipment. |
| Medication records lacked diagnosis or purpose for administration of medications. |
| Failure to follow prescriber's orders including missed medication administrations and incorrect medication availability. |
| Resident assessments and support plans were not updated to reflect significant changes in condition. |
| Directions for operating key-locking devices on Secure Dementia Care Unit doors were indecipherable. |
Report Facts
License Capacity: 79
Residents Served: 70
Secured Dementia Care Unit Capacity: 19
Residents in Secured Dementia Care Unit: 17
Current Hospice Residents: 4
Residents Age 60 or Older: 69
Residents with Mobility Need: 23
Total Daily Staff: 93
Waking Staff: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in multiple abuse and neglect findings, terminated for violations. | |
| Staff Member B | Failed to report abuse allegations and incidents, terminated for noncompliance. | |
| Staff Member C | Responsible for reporting incidents, involved in abuse reporting failures. | |
| Staff Member D | Witnessed verbal abuse, terminated unrelated to violation. | |
| Staff Member G | Witnessed staff laughing at resident during abuse incident. | |
| Staff Member H | Involved in abuse incident, terminated after investigation. | |
| Executive Operations Officer | Provided training, monitored compliance, and implemented corrective actions. | |
| Resident Wellness Director | Terminated due to failure to comply with state regulations and facility expectations. | |
| Director of Memory Care | Involved in review and monitoring of resident care and assessments. |
Inspection Report
Renewal
Census: 43
Capacity: 79
Deficiencies: 21
Jun 11, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 06/11/2024 and 06/12/2024 to review compliance with licensing regulations.
Findings
The inspection found multiple deficiencies including failure to post current licensing summaries, staff qualification issues, inadequate CPR/First Aid coverage, unsanitary conditions, equipment safety concerns, medication storage and labeling violations, incomplete resident records, and issues with emergency phone numbers and fire drill documentation. Plans of correction were accepted and fully implemented by 07/24/2024.
Deficiencies (21)
| Description |
|---|
| Current licensing inspection summaries were not posted in a conspicuous and public place in the home. |
| Direct Care Staff Member A attended a non-U.S. educational institution without a Department-issued waiver. |
| Only one staff member with CPR and first aid certification was present during a night shift when 55 residents were in the home. |
| An uncovered enabler device on a resident's bed posed a potential risk of entrapment. |
| Three drawers in a medication cart contained dirt, dust, hair, and trash creating unsanitary conditions. |
| Bathroom ventilation fan in resident room #112 was inoperable. |
| Emergency phone numbers posted were incorrect or missing near phones. |
| Heavy accumulation of lint in the dryer lint trap in resident room #322. |
| Fire drill records did not include actual evacuation times or number of residents present at the time of drills. |
| Resident #1's medical evaluation was overdue prior to being completed on 2/1/24. |
| Menus were not posted one week in advance as required. |
| Staff Member B transported residents without completing required direct care staff training. |
| Medication containers with loose tablets/capsules were found in medication carts. |
| Loose white pills were found in medication carts. |
| A bottle of pills in a medication cart was unlabeled and unidentifiable. |
| Resident #7's glucometer was not calibrated to the correct date and time. |
| Resident medications were missing diagnosis or purpose on Medication Administration Records. |
| Resident support plans did not include specific information about bedside mobility devices. |
| Directions for egress from the secured dementia care unit locking mechanism were posted in a disguised manner not permitting immediate egress. |
| Resident records did not include photographs no more than 2 years old. |
| Medication office containing resident medical files was unlocked, unattended, and accessible. |
Report Facts
Residents served: 43
License capacity: 79
Residents in secured dementia care unit: 12
Capacity of secured dementia care unit: 19
Hospice residents: 4
Staff total daily: 66
Waking staff: 50
Residents with mobility need: 23
Residents aged 60 or older: 67
Residents present during CPR deficiency: 55
Medication containers found: 6
Loose white pills found: 2
Unlabeled pills found: 30
Inspection Report
Complaint Investigation
Census: 61
Capacity: 79
Deficiencies: 2
Feb 1, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 02/01/2024.
Findings
The inspection found deficiencies related to medication management, specifically medications and syringes not being locked and medications not stored properly under required conditions. A plan of correction was submitted and fully implemented by 02/20/2024.
Complaint Details
The visit was complaint-related as stated under Inspection Information with a reason of Complaint.
Deficiencies (2)
| Description |
|---|
| Medications and syringes were found unlocked, unattended, and accessible on medication carts. |
| Medications were not stored in an organized manner under proper conditions of sanitation, temperature, moisture, and light as required. |
Report Facts
License Capacity: 79
Residents Served: 61
Memory Care Capacity: 19
Memory Care Residents Served: 14
Hospice Residents: 6
Resident Support Staff: 81
Waking Staff: 61
Residents Age 60 or Older: 59
Residents with Mobility Need: 20
Inspection Report
Renewal
Census: 58
Capacity: 79
Deficiencies: 11
Apr 4, 2023
Visit Reason
The inspection was conducted for renewal and complaint reasons as part of a full unannounced inspection on 04/04/2023 and 04/05/2023.
Findings
The inspection identified multiple deficiencies including breaches in record confidentiality, insufficient first aid/CPR trained staff during night shifts, incomplete direct care staff training, missing annual fire safety training, unsafe resident personal equipment, lack of grab bars in bathrooms, outdated emergency procedures, missing fire department notification, incomplete medical evaluations, improper medication equipment calibration, and unsigned support plans. Plans of correction were accepted and implemented by early June 2023.
Deficiencies (11)
| Description |
|---|
| Resident narcotic count binders were unlocked and unattended on medication carts, and resident information was accessible on an unattended computer screen. |
| Only one staff person certified in first aid, obstructed airway techniques, and CPR was present during night shifts when 58 residents were in the home. |
| Direct Care Staff Member A provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
| Staff Members B and C did not receive required annual training in fire safety and emergency preparedness during the 2022 training year. |
| Resident #1 had an enabler bar on the bed with an opening exceeding FDA guidelines, posing a potential entrapment or fall hazard. |
| No grab bar, hand rail, or assist bar was located near the bathroom toilet in a resident room. |
| The home's written emergency procedures had not been reviewed since 2022 and were not submitted to the local emergency management agency. |
| The home lacked documentation of written notification to the local fire department regarding the home's address, bedroom locations, and evacuation assistance needs. |
| Resident #3's annual medical evaluation did not include the date of evaluation or form completion. |
| Resident #1's glucometer was not calibrated to the correct date or time. |
| Residents #3 and #4 participated in support plan development but neither the resident nor the assessor signed the support plan. |
Report Facts
Residents present during inspection: 58
Total licensed capacity: 79
Memory Care capacity: 19
Memory Care residents served: 14
Residents served: 58
Residents age 60 or older: 56
Residents with mobility needs: 17
Residents with mental illness: 1
Residents with intellectual disability: 0
Residents with physical disability: 0
Inspection Report
Renewal
Census: 59
Capacity: 79
Deficiencies: 10
Mar 29, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for THE WOODS AT CEDAR RUN.
Findings
The inspection found multiple deficiencies including failure to report a medication error, unsigned resident-home contracts, insufficient staff certified in first aid and CPR during night shifts, evacuation drill exceeding maximum allowed time, unsecured medications, incomplete medication administration records, failure to report medication refusal, missing signatures on support plans, incomplete preadmission screenings, and delayed admission support plans. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (10)
| Description |
|---|
| Failure to report a medication error when Resident #1 missed a weekly dose of prescribed medication. |
| Resident-home contracts for Resident #1 and Resident #2 were not signed by the residents. |
| Not at least two staff persons trained and certified in first aid and CPR present during the 11PM to 7AM shift based on census. |
| Fire drill evacuation time of 14 minutes and 9 seconds exceeded the maximum allowed time of 13 minutes. |
| Medications and syringes were not locked and accessible in Resident #5's room and bathroom. |
| Medication administration record for Resident #1 lacked glucometer reading for 3/29/22 despite physician order for daily blood sugar check. |
| Refusal of medication by Resident #4 on 3/19/22 was not reported to the prescriber. |
| Resident Assessment and Support Plans for Resident #1 and Resident #3 were not signed by the staff person who developed the plans. |
| Written cognitive preadmission screening was not completed for Resident #2 prior to admission to the Secure Dementia Care Unit. |
| Resident #4's initial support plan was completed after admission to the Secure Dementia Care Unit, not within 72 hours as required. |
Report Facts
License Capacity: 79
Residents Served: 59
Secured Dementia Care Unit Capacity: 19
Residents Served in Dementia Care Unit: 13
Hospice Residents: 6
Evacuation Time: 849
Maximum Allowed Evacuation Time: 780
Staff Certified in First Aid and CPR Required: 2
Total Daily Staff: 74
Waking Staff: 56
Inspection Report
Renewal
Deficiencies: 0
Aug 31, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections of the facility on 08/31/2021 and 09/03/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Loading inspection reports...
