Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Cedar Crest Post Acute during CMS and state inspections, most recent first.
A resident with end stage kidney disease and emphysema was administered multiple medications, including antihypertensives (metoprolol, amlodipine), Ritalin, Eliquis, and Protonix, even though these drugs were not present on the resident’s physician orders. Review of the April medication orders confirmed that these medications had not been prescribed, and the DON acknowledged that the resident received medications without a physician order, resulting in a cited nursing services deficiency.
Failure to assess two residents for self-administration of medications. One resident with HF, DM, and CKD had intact cognition on MDS, but there was no documented self-administration assessment; an unsecured cup with 12 unidentified pills was left on the bedside table, and RN confirmed leaving the meds there. Another resident with frontotemporal neurocognitive disorder also had intact cognition on MDS, but no documented assessment was found; a cup with seven unidentified pills was observed in the room, and an LPN confirmed the meds were given during the 6:00 a.m. med pass. The DON confirmed neither resident was assessed or approved per policy.
A resident with anxiety and psychotic disorder with hallucinations had two PRN lorazepam orders for anxiety-related symptoms, and neither order included a stop date. The MAR showed repeated administration of both PRN orders, and there was no documented physician re-evaluation beyond 14 days for the second PRN anti-anxiety order. Staff continued giving both PRN doses.
A resident with stroke, heart disease, atrial fibrillation, and type 2 DM had an MDS that incorrectly showed no insulin injections or anticoagulant/antiplatelet use in Section N, even though the MAR documented daily insulin, anticoagulant, and antiplatelet administration. The DON confirmed the MDS did not accurately reflect the resident’s medication status.
Failure to follow MD orders for a resident with HTN and CHF. Staff gave metoprolol without documenting BP or pulse and administered it outside ordered SBP parameters. Staff also missed ordered weights and did not document notifying the MD of significant wt gains.
Incorrect Tube Feeding Water Flush Programming: A resident with a hx of brain injury, dysphagia, and a trach received enteral nutrition via feeding tube and had low sodium. Although the provider ordered 150 mL free water flushes every 6 hours, the pump was observed programmed for 150 mL every 4 hours, resulting in 300 mL more water per day than ordered. An LPN said the pump was not verified against the updated order, and the DON confirmed the mismatch.
Medication administration errors on the second floor resulted in a 5.26% error rate. An RN gave Advair Diskus before the ordered ipratropium-albuterol for a resident with asthma and COPD, and gave Senna Plus instead of ordered sennosides for another resident. The DON confirmed both errors.
Unsanitary storage was observed in a resident refrigerator on the MedBridge unit. The top shelf had crumbs and dried liquid debris, the middle shelf had a white sticky substance with part of a plastic bag stuck to it, and the bottom area under the drawers had a thick layer of dark sticky substance.
Staff failed to follow TBP and enhanced barrier precaution requirements for residents with confirmed COVID-19 and for a resident requiring enhanced barrier precautions. An LPN and an NA entered rooms wearing only masks and gloves when signs and orders required gowns and eye protection for droplet/contact precautions, and an NA also changed linens for a resident with a trach and feeding tube without wearing a gown during high-contact care. The DON confirmed the policies were not followed.
A resident with multiple chronic conditions and a risk for falls did not have access to a reacher, an assistive device specified in her care plan. The resident reported not having the reacher, and observation confirmed it was missing from her room. An LPN supervisor verified that the reacher was a current intervention but was not available to the resident.
Two residents with significant self-care deficits were not provided with accessible call bells or timely assistance with ADLs. One resident was left in bed in an improperly fastened gown, with uncombed hair and no evidence of hygiene care, and could not reach her call bell. Another resident was unable to locate her call bell and was observed calling out for help to use the bathroom. These lapses resulted in unmet needs and compromised dignity.
A facility failed to create a comprehensive care plan for a resident with urinary retention, Parkinson's disease, and dementia. The resident's care plan lacked interventions for urinary incontinence and cognitive decline, as identified in the assessment. The DON confirmed the absence of necessary documentation.
Unordered Medications Administered to a Resident
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered when a resident was given multiple medications that had not been ordered by the physician. The resident, identified as CR 1, had diagnoses including end stage kidney disease and emphysema. Facility documentation showed that on April 16, 2026, this resident was administered metoprolol and amlodipine for hypertension, Ritalin for attention deficit disorder, Eliquis to prevent blood clots, and Protonix to reduce stomach acid. Review of the resident’s physician orders for April 2026 revealed that none of these medications were ordered for this resident. In an interview on April 30, 2026, at 10:30 a.m., the Director of Nursing confirmed that the resident had been administered medications that were not prescribed by the physician, constituting a failure in nursing services as cited under 28 Pa. Code 211.12(d)(1)(3)(5).
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess whether two residents were capable of self-administering medications in accordance with facility policy. The policy required that the attending physician, with the interdisciplinary care planning team, determine that a resident had the decision-making capacity to self-administer medications safely, and that the resident’s cognitive and physical abilities be evaluated and documented in the medical record and care plan. For one resident with diagnoses including heart failure, diabetes, and chronic kidney disease, the MDS indicated cognition was intact, but there was no documented evidence of an assessment for self-administration. During observation, a medicine cup containing 12 unidentified pills was found unsecured on the bedside table, and the resident stated the pills were morning medications left there by the nurse. RN 1 later confirmed leaving the medications on the bedside table. For the second resident, who had a diagnosis of frontotemporal neurocognitive disorder, the MDS also indicated cognition was intact, but there was no documented evidence that the resident had been assessed for the ability to self-administer medication. During observation, a medicine cup containing seven unidentified pills was found in the resident’s room, and the resident stated that another nurse had brought them but he could not remember when. LPN 1 confirmed the pills were given during the 6:00 a.m. medication pass. The DON later confirmed that both residents were not assessed or approved to self-administer medications as required by facility policy.
Unreviewed PRN Lorazepam Orders
Penalty
Summary
The facility failed to ensure that a resident was free from potential chemical restraints related to psychotropic medication use. Resident 93 had diagnoses including anxiety and psychotic disorder with hallucinations. On August 27, 2025, a physician ordered lorazepam every 24 hours as needed for anxiety and sleep, and the order did not include a stop date. The resident’s MAR showed the medication was administered two times in October 2025 and three times in November 2025. On October 14, 2025, a second physician order was entered for lorazepam every 24 hours as needed for anxiety and agitation, also without a stop date. The MAR showed this second PRN lorazepam order was administered one time in October 2025 and five times in November 2025. There was no documented evidence that the physician re-evaluated continued use beyond 14 days for the second PRN anti-anxiety medication order, and staff continued to administer both PRN lorazepam orders.
MDS Assessment Did Not Match Medication Administration Record
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected Resident 11’s medication status. Resident 11 had multiple diagnoses including stroke, nontraumatic intracerebral hemorrhage, unspecified sequelae of other cerebrovascular disease, coronary artery disease, heart failure, hypertension, occlusion and stenosis of bilateral carotid arteries, atrial fibrillation, type 2 diabetes mellitus, and long-term insulin use. The MDS assessment dated September 19, 2025, incorrectly indicated in Section N that the resident did not receive insulin injections or an anticoagulant or antiplatelet during the previous seven days, even though the 2025 MAR for September showed daily administration of an anticoagulant, an antiplatelet, and an insulin injection as ordered by the physician. The DON confirmed in interview that the MDS assessment did not accurately reflect the resident’s medication status.
Failure to Follow Medication and Weight Monitoring Orders
Penalty
Summary
The facility failed to implement physician orders for Resident 151, who had diagnoses of hypertension and chronic systolic congestive heart failure. On November 3, 2024, the physician ordered metoprolol once daily with instructions not to administer it if systolic blood pressure was below 110 mm/Hg or if pulse was below 60 beats per minute. Review of the MAR for August, September, October, and November 2025 showed that staff failed to record blood pressure or pulse before giving the medication 10 times in August, seven times in September, and four times in October. The MAR also showed that metoprolol was administered three times in October and three times in November when the resident's systolic blood pressure was below 110 mm/Hg. In addition, on December 30, 2024, the physician ordered weights every Monday, Wednesday, and Friday for CHF treatment and notification if the resident gained more than 2 lbs. in 24 hours or 5 lbs. in a week. The MAR showed missed weights on August 4 and 18, September 10, and November 24, 2025, and documented weekly weight gains greater than 5 lbs. on multiple occasions, with no evidence that the physician was notified. The DON confirmed that the medication was given outside of parameters, weights, blood pressure, and pulse were not recorded, and the physician was not notified of the weight changes.
Incorrect Tube Feeding Water Flush Programming
Penalty
Summary
The facility failed to provide sufficient enteral nutrition to maintain proper hydration and health in accordance with the physician's order for a resident receiving nutrition through a feeding tube. The resident had a history of brain injury, difficulty swallowing, and a tracheostomy, and was dependent on staff for activities of daily living and unable to express needs or understand others. The resident received more than 51 percent of nutrition through an enteral feeding tube, and bloodwork showed a low sodium level of 131 millimoles per liter. A nutrition progress note recommended decreasing free water flushes from 200 mL every six hours to 150 mL every six hours due to the low sodium level, and a physician's order directed 150 mL of free water flushes every six hours. However, observations showed the tube feeding pump was programmed to deliver 150 mL every four hours, or six times per day, for a total of 900 mL per day. An LPN stated they did not verify the pump was programmed based on the updated physician's order, and the DON confirmed the pump had not been programmed to match the order and that the resident had received 300 mL per day more water than ordered.
Medication Administration Errors Exceeded 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% on the second floor during observed medication administration. During observation of medication pass on November 25, 2025, surveyors identified 38 medication opportunities and two medication errors, resulting in a 5.26% medication administration error rate. Resident 152 had diagnoses including asthma, COPD, and coronavirus 2019. The physician's order required 3 ml of ipratropium-albuterol inhalation solution to be given every 12 hours and administered before Advair Diskus 500-50 mcg. During the medication pass, RN 2 administered the Advair Diskus before giving the ipratropium-albuterol solution, which was not in accordance with the order. Resident 170 had diagnoses including frontotemporal neurocognitive disorder, anemia, and high blood pressure. The physician's order required sennosides 8.6 mg every 12 hours, but RN 2 administered Senna Plus instead, which was the incorrect medication. The DON confirmed both errors during interview.
Unsanitary Storage in Resident Refrigerator
Penalty
Summary
The facility failed to store food in a sanitary manner on one of three nursing units, MedBridge. During observation of the MedBridge resident refrigerator on November 25, 2025, at 9:34 a.m., the top shelf was found to have a thick layer of crumbs and dried liquid debris. The middle shelf had an area of white sticky substance with part of a plastic bag stuck to the shelf, and the area along the length of the bottom of the refrigerator under the drawers had a thick layer of dark sticky substance.
Failure to Follow Isolation and Barrier Precautions
Penalty
Summary
The facility failed to follow its infection prevention and control policies for transmission-based precautions and enhanced barrier precautions on one nursing unit. Facility policies reviewed stated that residents with communicable diseases were to be placed on the appropriate precautions, with posted signs and required PPE, including gowns and eye protection for droplet/contact precautions related to COVID-19 and gowns and gloves for high-contact care under enhanced barrier precautions. The Director of Nursing later confirmed that droplet and contact precautions should have been implemented and that staff did not follow the policies. Clinical record review showed that multiple residents had recently confirmed COVID-19 infections and physician orders directing droplet/contact precautions for ten days. Observations on November 24, 2025, showed an LPN entering several of these residents’ rooms wearing only gloves and a mask, while signs on the doors indicated that gowns and eye protection were required. The LPN did not wear a gown or eye protection in the rooms of residents with confirmed COVID-19, including residents who had positive tests on November 16, November 18, and November 20, 2025. For another resident with diagnoses including history of brain injury, dysphagia, a feeding tube, and a tracheostomy, the care plan required enhanced barrier precautions for high-contact care activities. Observations showed an NA entering the room, stripping the bed, and removing soiled linens while wearing a mask and gloves, but not a gown, despite signage indicating that a gown was required for high-contact resident activities. The resident was dependent on staff for activities of daily living and unable to express needs or understand others.
Failure to Provide Required Assistive Device per Care Plan
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease, osteoarthritis, and osteoporosis, who required staff assistance for mobility and was able to communicate her needs, did not have access to a reacher as specified in her care plan. The care plan included an intervention for staff to ensure the reacher was within the resident's reach to address her risk for falls. During an interview, the resident reported not having her reacher for some time and expressed a desire to have it. Observation of the resident's room confirmed the reacher was not present, and a Licensed Practical Nurse Supervisor was unable to locate it. The supervisor acknowledged that the reacher was a current intervention for the resident, but it was not available for her use.
Failure to Accommodate Resident Needs and Maintain Dignity
Penalty
Summary
The facility failed to accommodate the needs and maintain the dignity of two residents by not ensuring their access to call bells and by not providing timely assistance with activities of daily living (ADLs). One resident, who had a history of stroke with hemiplegia, aphasia, dysphagia, and depression, required maximum assistance with self-care, including dressing and toileting. Despite care plan interventions for staff to anticipate and meet her needs, observations revealed that she was left in bed wearing only a hospital gown that was not properly fastened, with her hair uncombed and no evidence of hygiene care. Her call bell was tangled and out of reach, and she was unaware of its location, preventing her from calling for assistance. When later observed dressed and groomed, she indicated improved well-being. Another resident, diagnosed with diabetes, fibromyalgia, and major depressive disorder, also had an ADL self-care deficit and was to be encouraged to use the call bell for assistance. However, she was observed calling out for help to use the bathroom, unable to locate her call bell, which was found draped over the nightstand and out of her reach. These findings demonstrate that the facility did not reasonably accommodate the needs and preferences of these residents, nor did it maintain their dignity as required.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 194, to address their specific needs as determined by a comprehensive assessment. Resident 194 was admitted with diagnoses including urinary retention, Parkinson's disease, and dementia. The Minimum Data Set Care Area Assessment summary indicated that the resident's urinary incontinence and cognitive decline/dementia should be addressed in the care plan. However, a review of the clinical records revealed that there were no documented interventions for these issues in the current care plan. This deficiency was confirmed by the Director of Nursing during an interview, acknowledging the absence of necessary care plan documentation for the identified care areas.
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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 Allentown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lehigh Valley Hospital Tsu | 1.1 mi | ★★★★★ | 1 | 0 |
| Cedarbrook Senior Care And Rehabilitation | 1.6 mi | ★★★★★ | 8 | 0 |
| Phoebe Allentown Health Care Center | 2.5 mi | ★★★★★ | 1 | 1 |
| Luther Crest Nursing Facility | 3 mi | ★★★★★ | 5 | 0 |
| Complete Care At Lehigh Llc | 3 mi | ★★★★★ | 6 | 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.