Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Concordia At The Cedars during CMS and state inspections, most recent first.
Failure to assess, document, and notify physician for low CBG readings. Two residents with DM had repeated hypoglycemic episodes, including readings in the 60s and 30s, yet staff did not consistently assess for hypoglycemia, monitor response to treatment, document interventions, or notify the MD as ordered. One resident had sliding-scale insulin orders with no ordered hypoglycemic protocol in the chart, while the other had oral hypoglycemic and glucagon orders but still had multiple low CBGs with incomplete documentation and no physician notification.
Failure to Notify Ombudsman of Transfers and Discharges: The facility did not provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for 11 of 11 months. Facility policy required transfer/discharge notices to be given to the resident and representative in a language and manner they could understand, and to keep evidence that the notice was sent to the Ombudsman. Document review found no evidence of Ombudsman notification for resident transfers and discharges, and the NHA confirmed the omission.
The facility failed to investigate and report potential abuse for two residents. One resident developed a skin tear with no investigation into its cause, while another had multiple bruises with no thorough investigation conducted. The DON confirmed the lack of investigation and failure to determine the root cause of these injuries.
The facility failed to prevent potential cross-contamination during medication administration for two residents. A nurse was observed removing oral medication tablets into her ungloved hand before placing them into a medication cup, contrary to the facility's policy. This was confirmed by the nurse and facility management.
A facility failed to assess and care plan for a cognitively intact resident who wished to self-administer medications. The resident, with diabetes and heart failure, was observed with a medicine cup and pill, but staff were unsure of the assessment process. The DON confirmed the oversight for one of three residents wishing to self-administer.
A facility failed to administer prescribed medications for bowel management to a resident with a history of atrial fibrillation, traumatic brain injury, and stroke. Despite physician orders for milk of magnesia, bisacodyl, and enema, the resident's care plan lacked bowel management interventions, and records showed no bowel movements or medication administration over several months. The DON confirmed the failure to provide necessary care, violating multiple Pennsylvania Code regulations.
The facility failed to serve food and beverages in accordance with professional standards for food safety on the 3rd Floor Nursing Unit. Meals were served from an uncovered steam table transported through hallways, and a dietary aide handled food without changing gloves or washing hands. The process was confirmed by the Food Service Director and Nursing Home Administrator.
The facility failed to provide accessible grievance forms and boxes for residents and visitors in wheelchairs in both the front lobby and the third-floor nursing unit. The grievance boxes were not at a level accessible to those in wheelchairs and were placed within sight of staff, compromising anonymity. Additionally, the third-floor nursing unit did not have grievance forms available on multiple occasions.
The facility failed to review and revise the comprehensive care plans for two residents. One resident with severe cognitive impairment and another on antipsychotic medication did not have appropriate interventions included in their care plans. The Director of Nursing confirmed the deficiency, and the facility lacked a policy on care planning.
Failure to assess, document, and notify physician for low blood glucose readings
Penalty
Summary
The facility failed to assess, document, and notify physicians of decreased capillary blood glucose (CBG) levels for two residents with diabetes. The report states that the facility policy for hypoglycemia management required residents at risk for hypoglycemia to be observed for signs and symptoms of low blood glucose, to follow the hypoglycemic protocol when blood glucose was 70 mg/dl or below, to recheck blood glucose as indicated, to notify the practitioner as ordered, and to document the blood sugar and treatment per facility protocol. One resident had diagnoses including diabetes, dementia, and depression. The resident’s orders included Humalog sliding scale insulin with instruction to initiate hypoglycemic protocol for CBG 0-70, but the resident’s orders did not include an ordered hypoglycemic protocol. The record showed CBG readings of 69 and 61 on separate occasions. The eMAR and progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician order for hypoglycemic protocol was not followed. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. The second resident had diagnoses including diabetes, high blood pressure, and a history of falling. Orders included an oral hypoglycemic protocol, glucagon emergency injection kit for hypoglycemia, and Humalog sliding scale insulin with instruction to initiate hypoglycemic protocol for CBG 0-70. The record showed multiple low CBG readings, including 34, 62, 57, 59, 37, 67, 66, 53, 68, 67, 49, 53, and 66. The eMAR progress notes showed glucagon was given on two occasions, with follow-up CBGs of 168, but 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. One low CBG reading of 67 had no documentation noted. Staff interviews reflected varying understanding of when to treat, when to notify the physician, and what to document. The DON confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions related to blood glucose, and failed to follow physician’s orders for both residents.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for eleven of eleven months, covering the period from February 2025 through January 2026. Review of the facility’s Transfer and Discharge (including AMA) policy dated 1/15/26, with a prior review date of 1/16/25, indicated that transfer/discharge notices are to be provided to the resident and the resident’s representative in a language and manner they can understand, and that the facility will maintain evidence that the notice was sent to the Ombudsman. However, a review of facility documents on 2/24/26 found no documented evidence that the State Ombudsman Office had been notified of resident transfers and discharges during the 1/2025 through 1/2026 time frame. During an interview on 2/26/25 at 9:30 a.m., the Nursing Home Administrator confirmed that the facility had failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division during the past twelve months.
Failure to Investigate and Report Potential Abuse
Penalty
Summary
The facility failed to identify, investigate, and report potential abuse for two residents, R4 and R3. Resident R4, who was admitted with dementia, gait abnormalities, and a history of stroke, developed a skin tear on her right lower extremity. The injury was noted in a progress note and a skin observation tool, but there was no documentation of an investigation into the cause of the injury. The Director of Nursing confirmed that the facility did not thoroughly investigate the injury to determine its root cause or rule out potential abuse. Resident R3, admitted with a history of heart attack, pacemaker insertion, kidney disease, diabetes, and lung disease, developed multiple bruises on her right arm, including a large bruise that wrapped around her upper arm. Although the resident stated the bruising had been present for a long time, the facility could not identify a perpetrator. The Director of Nursing acknowledged that the facility failed to determine the root cause of the bruising and did not conduct a thorough investigation, despite indicating that abuse had been ruled out.
Failure to Prevent Cross-Contamination During Medication Administration
Penalty
Summary
The facility failed to prevent potential cross-contamination during medication administration for two residents. The facility's policy on Medication Administration, last reviewed on January 26, 2025, requires that medications be administered in accordance with professional standards to prevent contamination or infection. However, during a medication administration, Registered Nurse Employee E1 was observed removing oral medication tablets for two residents into her ungloved left hand before placing them into a medication cup. This action was confirmed by RN Employee E1 during an interview, acknowledging the potential for cross-contamination. The Nursing Home Administrator and the Director of Nursing also confirmed the facility's failure to prevent this potential cross-contamination during medication administration.
Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and care plan for the self-administration of medications for a cognitively intact resident who wished to do so. The resident, identified as R41, was admitted with diagnoses of diabetes and heart failure and was noted to be cognitively intact according to the Minimum Data Set assessment. During an observation, a medicine cup with a pill was found on the resident's overbed table, indicating the resident's interest in self-administering medication. When questioned, a registered nurse was unsure if the resident had been assessed or care planned for self-administration, despite acknowledging the resident's alertness and orientation. The Director of Nursing confirmed the facility's failure to assess and care plan for the resident's self-administration of medications, which was a requirement for one of the three residents who wished to self-administer their medications.
Failure to Administer Bowel Management Medications
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain bowel function for a resident, identified as Resident R53. The resident was admitted with diagnoses including atrial fibrillation, traumatic brain injury, and a history of stroke, requiring substantial assistance with toileting and was occasionally incontinent of bowel. Despite having physician orders for milk of magnesia, bisacodyl suppository, and enema to manage constipation, the resident's plan of care did not include goals and interventions related to bowel management. The resident's bowel records over several months showed no documentation of bowel movements, and the medication administration records revealed a lack of administration of the prescribed treatments. The Director of Nursing confirmed that the facility did not administer the necessary medications to maintain bowel function for the resident. This deficiency was identified through a review of clinical records and staff interviews, indicating a failure to adhere to the physician's orders and the resident's care needs. The report cites several Pennsylvania Code regulations that were not met, including those related to the responsibility of the licensee, management, resident rights, resident care policies, and nursing services.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to serve food and beverages in accordance with professional standards for food safety on the 3rd Floor Nursing Unit. During the lunch meal service, meals were served from a steam table in the kitchenette to the dining room, and then the steam table was transported to the hallway of resident rooms 300-318. Plates on the steam table were not covered during transportation, and various carts were lined up beside the steam table in the hallway. A nurse was observed pushing a medication cart between the steam table and the handrail. Dietary Aide Employee E2 was seen touching resident trays, plate covers, and meal tickets, then cutting baked potatoes and plating them without changing gloves or washing hands, which was confirmed by the employee during an interview. The steam table was then moved to the hallway of resident rooms 319-331, where meal trays were assembled and served in the same manner. During this time, several visitors, a resident in a wheelchair pushed by staff, and another resident ambulating in a wheelchair passed between the steam table and the handrail. The Food Service Director confirmed that the facility had been using this meal service process since May 2023. The Nursing Home Administrator also confirmed the use of this process since April 2023. The facility's actions were found to be in violation of professional standards for food safety as outlined in their policy and state regulations.
Failure to Provide Accessible and Anonymous Grievance Process
Penalty
Summary
The facility failed to provide accessible grievance forms and boxes for residents and visitors in wheelchairs in both the front lobby and the third-floor nursing unit. Observations revealed that the grievance boxes were not at a level accessible to those in wheelchairs and were placed within sight of the receptionist and the nurses' station, compromising the anonymity of the grievance process. Additionally, the third-floor nursing unit did not have grievance forms available for residents and visitors on multiple occasions. Interviews with staff confirmed these deficiencies. A Registered Nurse acknowledged the absence of grievance forms on the third floor, attributing it to running out of forms. The Nursing Home Administrator was also informed about the inaccessibility of the grievance boxes and the lack of opportunity for residents and visitors to file anonymous grievances. These actions and inactions are in violation of the facility's policy to support residents' and family members' rights to voice grievances without fear of discrimination or reprisal.
Failure to Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for two residents, R8 and R39. Resident R8, who was admitted with diagnoses including dementia, high blood pressure, and anxiety, had a BIMS score indicating severe cognitive impairment. Despite multiple progress notes indicating severe impairment, forgetfulness, and the need for crushed medication and mechanical soft food, the care plan did not include resident-centered interventions for dementia. Additionally, Resident R39, who was readmitted with vascular dementia, diabetes, and high blood pressure, was taking an antipsychotic medication as per a physician's order. However, the care plan did not include interventions for the use of antipsychotic medication. During an interview, the Director of Nursing confirmed that the facility failed to complete a resident-centered care plan for both residents. The facility was also unable to provide a policy regarding care planning, which further highlights the deficiency in ensuring comprehensive and individualized care plans for residents with specific medical and cognitive needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monroeville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Physical Rehabilitation | 0 mi | ★★★★★ | 0 | 0 |
| Monroeville Post Acute | 0.7 mi | ★★★★★ | 18 | 0 |
| Woodhaven Health & Rehab Center | 0.8 mi | ★★★★★ | 17 | 0 |
| Wecare At Monroeville Rehabilitation And Nsg Ctr | 1.8 mi | ★★★★★ | 48 | 2 |
| Wecare At Murrysville Rehab And Nursing Center | 2.6 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.