Concordia At The Cedars
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroeville, Pennsylvania.
- Location
- 4363 Northern Pike, Monroeville, Pennsylvania 15146
- CMS Provider Number
- 396059
- Inspections on file
- 23
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Concordia At The Cedars during CMS and state inspections, most recent first.
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 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.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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